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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.
9
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
14
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
20
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
29
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