INTRODUCTION
Japan has the highest proportion of individuals aged ≥65 years globally, with aging rate accelerating more rapidly compared to Western countries. Therefore, extending healthy life expectancy—the period during which individuals can live independently without requiring long-term care—and narrowing the gap between healthy and average life expectancies have become critical challenges in building a sustainable aging society. Two key conditions that significantly impact healthy life expectancy are frailty and locomotive syndrome (LS). In 2022, the Japanese Medical Science Federation issued the “Medical Declaration for Overcoming Frailty and Locomotive Syndrome” to address the following issues.1) Frailty is defined as “a state in which resilience to stressors is diminished due to a decline in reserve capacity associated with aging” and is characterized by its multifaceted nature and reversibility.2) LS refers to “a decline in mobility due to musculoskeletal disorders” and is closely related to physical frailty.3-5) Neither concept necessarily regards aging as an irreversible process but rather as a condition that can be prevented. They share the commonality that the social implementation of interventions and measures based on this perspective should be promoted.1)
As a countermeasure, three key factors—exercise, good nutrition, and social participation—are essential for preventing frailty.6) In fact, one study reported that individuals who do not engage in any of these three components have a 7.52 times higher prevalence of frailty compared to those who implement all three components.7) Among these factors, “social participation” is considered the initial gateway to frailty progression. One study revealed that older adults classified as having socially frailty had a 1.7 times higher risk of developing new long-term care needs within 1 year, highlighting its importance as a protective factor.8) Furthermore, a higher rate of social participation activities has been associated with a lower risk of developing frailty and pre-frailty.9,10) Additionally, the frequency and overlap of activities contribute to reduced frailty risk.11-14)
There are numerous reports on the impact of exercise and nutrition on LS.15-18) Notably, although it has been shown that older adults classified as having social frailty are not associated with new-onset LS after 2 years,19) evidence on the relationship between LS and social participation is limited. Given this, few studies have evaluated frailty and LS simultaneously.20-23) Therefore, there is a need for research and the development of countermeasures to comprehensively address frailty and LS simultaneously, while also exploring their association with social participation.
Accordingly, this study aimed to examine the association between the frequency of participation in a community-based long-term care prevention program and social participation and frailty and LS, among community-dwelling older adults. Additionally, analyses for men and women were conducted separately.
MATERIALS AND METHODS
Study Design
This cross-sectional study was conducted between April 2023 and March 2024. In accordance with the Declaration of Helsinki, this study was approved by the Ethics Committee of the International University of Health and Welfare (Approval No. 18-Io-158-2). Informed consent was obtained from all participants for the use of personal information, and data were collected accordingly.
Study Setting and Participants
This study included 522 older adults residing in City A, Tochigi Prefecture, who participated at least once in a long-term care prevention program during the survey period from April 2023 to March 2024. After excluding individuals with missing questionnaire data (n=29) and those younger than 65 years (n=7), a total of 486 participants (mean age 80.4±6.9 years; 92 men, 394 women) were included in the analysis (Fig. 1).
Participation Frequency in the Preventive Care Awareness Program and Group Classification
Participant recruitment was conducted by the city office, which contacted representatives from approximately 30 community-based “Kayoi-no-ba” locations in the city. These representatives then invited local residents who were potential candidates for participation.24) Additionally, recruitment was conducted through the city’s public relations magazine. Residents were able to participate voluntarily in the program, which was held three times a year at the Kayoi-no-ba location nearest to their residence, in addition to sessions conducted at the main city hall. The participants were classified into groups based on the frequency of their participation in the long-term care prevention program held from April 2023 to March 2024. Those who participated once were categorized into the “Low participation” group, those who participated twice into the “Medium participation” group, and those who participated three or more times in the “High participation” group. All participants had the functional mobility to attend the Kayoi-no-ba, either independently or with transportation support such as shuttle buses.
Contents of the Preventive Care Awareness Program
The preventive care awareness program was structured as a 2-hour session. It began with a health check conducted by municipal staff, which included interviews regarding the participants’ underlying conditions and medical history, as well as confirmation of vital signs on the day of participation. Following the health check, the main program, lasting approximately 1 hour, was implemented. It consisted of preventive lectures on topics such as exercise, nutrition, and oral care, physical fitness assessments, and integrated cognitive and physical exercises. These components were scheduled to prevent overlap within the same Kayoi-no-ba location. Qualified professionals including nurses, physiotherapists, occupational therapists, speech-language-hearing therapists, certified orthoptists, and dental hygienists took turns in leading the main program. In addition to the main program, group exercise sessions were conducted. Adequate break times were ensured both within and between program components.
Frailty and Locomotive Syndrome
Frailty was assessed using the Questionnaire for Medical Check-up of the Old-Old (QMCOO), which consists of 10 domains (health condition, mental health, eating behavior, oral function, body weight loss, physical function and falls, cognitive function, smoking, social participation, and social support) and 15 items.25) Each item and its corresponding QMCOO score are listed in Supplementary Table S1. The total score ranged 0–15, with higher scores indicating more severe frailty. In accordance with previous studies, a score of 4 or higher was considered indicative of frailty,26-28) and both the number of individuals meeting this criterion and the total QMCOO score were calculated.
LS was assessed using the 5-question Geriatric Locomotive Function Scale (GLFS-5) (Supplementary Table S2). A GLFS-5 score of 6 or higher was considered indicative of LS,29) thus both the number of individuals meeting this criterion and the total GLFS-5 score were calculated.
Other Variables
Basic attributes including sex, age, and residential area were also collected. Residential areas were categorized into three groups based on the octile values of population density, calculated from approximately 1,740 municipalities across Japan.30,31) Individuals residing in areas with a population density of 473.3 persons/km² or higher were classified as urban, those in areas with a population density between 91.5 and 473.3 persons/km² as suburban, and those in areas with a population density below 91.5 persons/km² as rural.
Statistical Analysis
Participants’ age, residential area, frequency of participation in long-term care prevention programs, frailty status and total score, and LS status and total score were compared between men and women using the chi-square test and Mann-Whitney U test. Additionally, for men and women separately, age, residential area, frailty status and total score, LS status and total score, and each questionnaire item were compared among the three groups based on participation frequency in long-term care prevention programs using the chi-square and Kruskal-Wallis tests. Furthermore, in men, a binary logistic regression analysis was conducted to examine the association between non-frailty/non-LS (dependent variable) and the frequency of participation in long-term care prevention programs (independent variable, categorized into three groups). The crude model included no adjustment variables; Model I was adjusted for age, and Model II was adjusted for age and residential area. Statistical analyses were performed using IBM SPSS Statistics version 25 (IBM Japan, Tokyo, Japan), with the significance level set at 5%.
RESULTS
Based on the frequency of participation in the preventive care awareness program, man participants were categorized into the low participation (n=36), medium participation (n=21), and high participation groups (n=35); woman participants were also categorized into the low participation (n=102), medium participation (n=114), and high participation groups (n=178). In this study, 141 participants (29.0%) were classified as having frailty and 160 (32.9%) were classified as having LS. Among man participants, 55 individuals (59.8%) were classified as having no frailty nor LS, 11 (12.0%) as having frailty only, 11 (12.0%) as having LS only, and 15 (16.3%) as having both frailty and LS. Among woman participants, 216 (54.8%) were classified as having no frailty nor LS, 44 (11.2%) as having frailty only, 63 (16.0%) as having LS only, and 71 (18.0%) as having both frailty and LS.
A comparison between men and women showed statistically significant differences in age (p=0.026) and frequency of participation in long-term care prevention programs (p=0.039) (Table 1). In the three-group comparison based on participation frequency in long-term care prevention programs, significant differences were observed among men in terms of frailty prevalence (p=0.022), QMCOO Q1 (p=0.040), and QMCOO Q5 (p=0.020). For LS, significant differences were found in the total GLFS-5 (p=0.015), GLFS-5 Q3 (p=0.004), Q4 (p=0.027), and Q5 (p=0.043) scores (Table 2). In contrast, no statistically significant differences were observed for any of the variables among women (Table 3).
The results of binary logistic regression analysis indicated that a higher frequency of participation in long-term care prevention programs was associated with a lower likelihood of frailty in all models. Specifically, the crude model (odds ratio [OR]=3.818; 95% confidence interval [CI], 1.197–12.178; p=0.024), Model I (OR=3.348; 95% CI, 1.028–10.903; p=0.045), and Model II (OR=3.603; 95% CI, 1.074–12.078; p=0.038) all showed significant associations (Table 4). No significant association was observed for LS in the binomial logistic regression analysis (Supplementary Table S3).
DISCUSSION
This study is the first to simultaneously evaluate frailty and LS in community-dwelling older adults and to examine the association between these two factors and the frequency of participation in long-term care prevention programs for men and women independently. While the positive impact of social participation on the health status of older adults is widely recognized. The relationship between LS and social participation has not been sufficiently explored in previous research. This study provides valuable evidence on the association between LS and social participation, further emphasizing the importance of long-term care prevention programs. This study offers new insights into the role of these programs regarding the health and functional abilities of older adults.
The results of the present study also showed a significant association between the frequency of participation in long-term care prevention programs and both frailty and specific LS subitems among men. In contrast, no statistically significant differences were observed among women. These differences may be influenced by social and psychological factors specific to men. Social participation of men is often centered on work and tends to decline after retirement.32) Previous studies have reported that a lack of social relationships among retired men is associated with higher mortality rates and a significant increase in depressive symptoms.33,34) In contrast, women’s social participation is typically based on family and community networks, with a greater emphasis on maintaining close interpersonal relationships.35-37) Due to these sex differences, women may be more likely to sustain continuous social connections through diverse social networks, regardless of their participation in long-term care prevention programs. As a result, the additional benefits of participating in these programs may not have been as pronounced for women as they were for men.
In this study, statistically significant differences were observed among men in the LS subitems related to “the ability to continue walking,” “difficulty in carrying a purchase of approximately 2 kg,” and “difficulty in performing moderately challenging household tasks.” These findings suggest that social participation may be related not only to frailty but also to the LS, which reflects mobility. Notably, the association between social participation and abilities related to activities of daily living, with a sex-specific difference, is particularly intriguing. Given the current need for more evidence on the relationship between LS and social participation, the present findings, which demonstrate this association using the GLFS-5, provide valuable insights that may contribute to future research.
Frailty is a multifaceted concept encompassing physical, psychological, and social dimensions. Meanwhile, LS focuses specifically on the musculoskeletal system and thus shares characteristics closely related to physical frailty. From this standpoint, LS can be viewed as a subset of the broader frailty concept. However, from an epidemiological perspective, it may be interpreted that frailty is included within LS, as LS is designed to detect earlier stages of functional decline. In this study, there were no substantial differences in the proportion of individuals with both LS and frailty, LS only, or frailty only, with each proportion falling within the 10% range. This indicates a diverse population that included older adults with either or both conditions. As mentioned above, LS and frailty share the common feature of being related to musculoskeletal functional decline, but they are based on different underlying concepts. Therefore, not all individuals necessarily fall into a clear inclusion relationship between the two. Notably, there was no overlap in the content of the assessment items used in this study, namely the QMCOO and GLFS-5. While frailty and LS share certain similarities, these assessment tools evaluate different aspects. Assessing both conditions together may enable a more comprehensive understanding of the health status of older adults.
The results of the present study suggest that long-term care prevention programs play an important role in maintaining the health of older adult men. Men may be more actively involved in long-term care prevention programs by assuming leadership and organizational roles in neighborhood associations and senior clubs.38) Additionally, as previously mentioned, mens’ social participation is often centered on their work. Therefore, after retirement, engaging in social activities such as sports groups, hobby clubs, and senior citizen associations is recommended.34) Furthermore, in Japan, many older men are regularly employed in a single occupation until retirement. Utilizing skills and knowledge later in life may enhance job satisfaction, which, in turn, could contribute to greater life satisfaction.39) Given these factors, rather than requiring men to build entirely new communities after retirement, it may be beneficial to design long-term care prevention programs that allow continuous engagement from middle-aged people, tailored to individual needs. Considering the findings of this study, along with previous research, the promotion of social participation among men and the maintenance of social participation among women are crucial. These results highlight the need for sex-specific approaches in community-based initiatives.
This study has several limitations. First, as this was a cross-sectional study, causal relationships could not be determined. In addition, as this survey was conducted in a single city, the sample size was limited, which might have led to a selection bias. Second, the definition of social participation in this study was limited to participation in the preventive care awareness programs organized by the city office. As no data were available for individuals who did not participate in these programs, the health status of non-participants could not be assessed. Therefore, the current study findings are limited to the participants only, and caution is warranted when making comparisons with nonparticipants or generalizing the results. Additionally, as this survey was conducted as part of a municipal administrative project, objective data on the participants’ detailed medical conditions (e.g., underlying diseases, medical history, or disabilities) were not available. It should also be noted that the program content included various activities, such as exercises and educational lectures, which should be considered a limitation of this study. Third, to minimize the burden on participants in the city’s long-term care prevention programs, this study used the GLFS-5 questioner, which has been validated for reliability and validity, instead of the GLFS-25.29)
In conclusion, this study revealed that a higher frequency of participation in long-term care prevention programs is associated with both frailty and components of LS among community-dwelling older men. These findings suggest that long-term care prevention programs may be associated with a favorable health status in older men. In the future, it will be necessary to develop accessible environments and effective intervention methods that encourage participation among older men, as well as to establish concrete strategies to promote social participation.
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