Abstract
[Purpose] In this study, we aimed to examine whether within-person changes in physical function are associated with changes in the social function domain score among community-dwelling older adults participating in a municipal community program. [Participants and Methods] A secondary analysis was conducted using longitudinal data of 191 older adults who completed baseline and 6-month follow-up assessments. The social function domain score was calculated using four items from the Eleven-Check questionnaire. Physical function was assessed using the Short Physical Performance Battery. In addition, handgrip strength, Timed Up and Go, and 4-m maximum-pace gait time tests were performed. Changes in each variable were calculated as the 6-month follow-up value minus the baseline value. In addition, Spearman’s rank correlation and multiple linear regression analyses were performed. [Results] Changes in the 4-m usual gait time were significantly correlated with changes in the social function domain score. In a regression model adjusted for age and sex, changes in 4-m usual gait time were associated with changes in the social function domain score. The model explained 9.3% of the variance. [Conclusion] 6-month changes in 4-m usual gait time were associated with changes in the social function domain score among community-dwelling older adults.
Key words: Gait speed, Social frailty, Older adults
INTRODUCTION
Population aging has resulted in frailty becoming a major public health concern, particularly in Japan, where the proportion of older adults is among the highest worldwide. Frailty is now recognized as a multidimensional state involving physical, psychological, and social domains, and is associated with increased risks of disability, hospitalization, and mortality1).
Within this framework, the social aspects of frailty have become increasingly important for sustaining independence among community-dwelling older adults. Social frailty, characterized by reduced social contact, participation, and social roles, is clinically consequential because it has been reported to predict subsequent disability and other adverse health outcomes and to increase the risk of future physical frailty2). Conversely, physical frailty has been reported to precede subsequent social frailty3), suggesting a bidirectional relationship between the social and physical domains.
These findings suggest that social aspects of frailty are related to physical function rather than representing an isolated domain of aging and health. Among physical functions, mobility has been repeatedly linked to social participation. In particular, usual gait speed is a simple physical performance measure that has been shown to predict subsequent functional limitations and major health-related outcomes4) and mortality in older adults5).
Therefore, usual gait speed may serve as an integrated indicator of general health and physiological reserve. Changes in life-space mobility and community participation have been observed among older adults receiving home-based rehabilitation6). The relationship between mobility and social aspects of frailty is clinically important because combined social and physical frailty markedly increases the risk of adverse health outcomes, including disability7).
However, most previous studies have focused on cross-sectional associations or baseline factors. Consequently, whether within-person changes in the social function domain score are associated with changes in specific physical function measures over time remains unclear. Clarifying which physical function measures are more closely related to changes in the social function domain score may help inform community-based approaches to supporting independence among older adults.
Therefore, in the present study, we used longitudinal data from a municipal community program to examine the relationship between changes in the social function domain score of the Eleven-Check questionnaire and changes in physical function measures, including the Short Physical Performance Battery [SPPB], handgrip strength, Timed Up and Go, and 4-m maximum-pace gait time. We hypothesized that changes in usual gait time, as an indicator of habitual mobility, would be more closely associated with changes in the social function domain score than changes in maximal-pace or task-specific physical performance measures. By focusing on change-to-change relationships, we aimed to clarify physical function measures related to changes in the social function domain score among community-dwelling older adults.
PARTICIPANTS AND METHODS
This study was a secondary analysis of a longitudinal observational dataset derived from a municipal community-based exercise program conducted in Komatsushima City, Tokushima Prefecture, Japan. The program was implemented as part of routine public health services, and data were prospectively collected. The participants were community-dwelling older adults who had continuously attended Kayoinoba (community salons) for at least 1 year. Trained personnel conducted baseline and 6-month follow-up assessments using standardized measurement protocols. Of the 197 individuals initially assessed, six were excluded from the analysis because they were younger than 65 years (n=3) or their data for key variables were missing (n=3). The final analysis sample comprised 191 participants (26 men and 165 women), with a mean age of 80.2 ± 5.7 years.
The study protocol was approved by the institutional ethics committee of our university (approval number: R7-24). As anonymized data routinely collected as part of a municipal health promotion program were used for this secondary analysis, the requirement for written informed consent was waived, and an opt-out consent procedure was adopted. Study information was publicly disclosed, participants were informed of their right to decline participation at any time, and all data were analyzed in an anonymized form.
Height and body weight were measured using a standard stadiometer and a calibrated digital scale, respectively. Body mass index (BMI) was calculated as body weight in kilograms divided by height in meters squared (kg/m2). Physical function was assessed using the SPPB8), which evaluates lower-extremity function by using three components: standing balance, usual gait speed, and chair stand performance. Each component was scored on a scale of 0 to 4, with the total score ranging from 0 to 12, with higher scores indicating better physical performance, according to established procedures. In addition to the SPPB subscores, the raw time values (seconds) for the 4-m usual gait test and five-repetition chair-stand test were recorded and used for analysis.
Bilateral handgrip strength was measured using a digital dynamometer (Grip-D, TKK5401; Takei Scientific Instruments, Niigata, Japan). Two trials at maximum effort were performed separately for each hand, with a brief rest period between trials. The highest value obtained from two trials for each hand was used as the representative value for that side. The Timed Up and Go (TUG) test was performed over a 3-m distance with instructions to walk as fast as safely possible (fast TUG). Although the original TUG test9) was designed to be performed at individuals’ usual or comfortable pace, the fast variant was adopted in this study to capture maximal mobility capacity. In addition to the usual-pace gait component of the SPPB, 4-m maximum-pace gait time (s) was measured to assess peak walking performance.
The social function domain score was calculated using the Eleven-Check questionnaire, an 11-item screening tool developed by the Tokyo Metropolitan Geriatric Hospital to identify frailty risk among community-dwelling older adults. The questionnaire captures multidimensional aspects of frailty, including nutrition/oral health, exercise, and social domains. In this study, the social function domain score was calculated from four items related to going out, eating with others, subjective vitality, and concern about forgetfulness. Each item was scored as 1 for the risk response and 0 otherwise, yielding a domain score ranging from 0 to 4. Higher scores indicated a greater risk in the social domain of frailty. This score was used because it represents the social domain included in the Eleven-Check questionnaire and was available in the routinely collected municipal program dataset. As these four items do not exclusively assess social interaction or participation, this score was treated as a screening-based indicator of the social function domain rather than a comprehensive measure of social functioning.
For each variable, change (Δ) was calculated as the 6-month follow-up value minus the baseline value. The primary outcome variable was the change in the social function domain score (ΔSocial). Explanatory variables included changes in physical function measures, including the ΔSPPB total score and subscores, Δ4-m usual gait time, ΔTUG (fast pace), Δ4-m maximum-pace gait time, and Δhandgrip strength. As shorter gait times reflect faster walking performance, negative values of Δgait time indicated shorter gait time. For descriptive analyses, the direction of change was classified as decrease, no change, or increase according to whether the 6-month follow-up value was lower than, identical to, or higher than the baseline value.
All statistical analyses were performed using a modified version of R Commander 4.3.2. Descriptive statistics were calculated to summarize participant characteristics, baseline and 6-month follow-up values, change values, and the direction of change. Bivariate associations between changes in the social function domain score (ΔSocial) and changes in physical function variables were examined using Spearman’s rank correlation coefficients to describe pairwise relationships.
Based on the study hypothesis and the observed bivariate associations, change in the 4-m usual gait time was selected as the primary explanatory variable for the age- and sex-adjusted regression model. Age and sex were included as forced covariates to account for potential confounding effects. Sex was entered as a categorical variable, with female as the reference category. Other physical function variables were examined descriptively but were not entered simultaneously into the regression model to evaluate the specific association between changes in 4-m usual gait time and changes in the social function domain score while avoiding model overfitting and multicollinearity.
Multiple linear regression analysis was conducted to examine whether changes in the 4-m usual gait time were associated with changes in the social function domain score in a regression model adjusted for age and sex. The model fit was evaluated using the coefficient of determination (R2 and adjusted R2). Multicollinearity was assessed using variance inflation factors (VIFs), and residual normality was examined using the Shapiro–Wilk test. Statistical significance was set at p<0.05.
RESULTS
Overall, 191 community-dwelling older adults (26 men and 165 women; mean age=80.2 ± 5.7 years) were included in the final analysis. All participants completed both baseline and 6-month follow-up assessments. At baseline, the mean total Eleven-Check questionnaire score was 3.68 ± 2.13, and the mean social function domain score (items 8–11) was 1.53 ± 1.06. The baseline physical function measures and Eleven-Check questionnaire scores are summarized in Tables 1 and 2. Baseline, 6-month follow-up, change values, and the direction of change are summarized in Table 3.
Table 1. Baseline characteristics of the participants (n=191).
| Variable | ||
| Age (years) | 80.2 ± 5.7 | |
| Sex, n (%) | ||
| Female | 165 (86.4) | |
| Male | 26 (13.6) | |
| Height (cm) | 151.1 ± 12.4 | |
| Weight (kg) | 53.6 ± 9.2 | |
| Body mass index (BMI, kg/m²) | 23.2 ± 3.3 | |
| SPPB total score (0–12 points) | 11.6 ± 0.9 | |
| Balance subscore (0–4 points) | 3.7 ± 0.7 | |
| 4-m usual gait subscore (0–4 points) | 4.0 ± 0.2 | |
| 4-m usual gait time (s) | 3.2 ± 0.7 | |
| Five Times Sit-to-Stand subscore (0–4 points) | 3.9 ± 0.4 | |
| Five Times Sit-to-Stand time (s) | 7.4 ± 2.2 | |
| Handgrip strength, right (kg) | 22.3 ± 6.6 | |
| Handgrip strength, left (kg) | 20.8 ± 6.1 | |
| Timed Up and Go (TUG) test (s) | 7.1 ± 1.9 | |
| 4-m maximum-pace gait time (s) | 2.6 ± 0.6 | |
Values are presented as mean ± SD or n (%).
SPPB: short physical performance battery; TUG: timed up and go.
Table 2. Baseline distribution of eleven-check questionnaire items and domain scores (n=191).
| Item | Risk response | n (%) | ||
| Nutrition and oral health (0–4) | ||||
| 1 | Do you try to keep a healthier diet than other people of your age and sex? | No | 25 (13.1) | |
| 2 | Do you eat vegetables and either meat or fish daily? | No | 91 (47.6) | |
| 3 | Can you chew hard foods like squid jerky or pickled radish? | No | 43 (22.5) | |
| 4 | Have you ever choked on tea or soup? | Yes | 42 (22.0) | |
| Nutrition/oral health domain score (0–4 points), mean ± SD | 1.1 ± 1.0 | |||
| Exercise (0–3) | ||||
| 5 | Is there any exercise that you do for at least 30 minutes per day, at least twice a week, and that you have continued for at least one year? | No | 69 (36.1) | |
| 6 | Do you walk or engage in a similar physical activity for at least one hour each day? | No | 62 (32.5) | |
| 7 | Do you think you walk faster than other people of your age and sex? | No | 77 (40.3) | |
| Exercise domain score (0–3 points), mean ± SD | 1.1 ± 1.0 | |||
| Social function (0–4) | ||||
| 8 | Do you go out less often than you did last year? | Yes | 58 (30.4) | |
| 9 | Do you eat with others at least once a day? | No | 68 (35.6) | |
| 10 | Do you consider yourself vibrant? | No | 63 (33.0) | |
| 11 | Do you worry more about forgetting things than anything else? | Yes | 104 (54.5) | |
| Social function domain score (0–4 points), mean ± SD | 1.5 ± 1.1 | |||
| Total Eleven-Check score (0–11), mean ± SD | 3.7 ± 2.1 | |||
Values are presented as n (%) or mean ± SD.
Each item was scored as 1 for the risk response and 0 otherwise. Higher scores indicate greater frailty risk.
The social function domain score used in the longitudinal analyses was calculated from items 8–11.
Table 3. Baseline, 6-month follow-up, and changes in social and physical function measures (n=191).
| Variable | Baseline | 6-month follow-up |
Change | Direction of change, n (%) | ||
| Decrease | No change | Increase | ||||
| Social function domain score (0–4 points) | 1.5 ± 1.1 | 1.7 ± 1.1 | 0.1 ± 1.1 | 42 (22.0) | 94 (49.2) | 55 (28.8) |
| SPPB total score (0–12 points) | 11.6 ± 0.9 | 11.5 ± 0.9 | 0.0 ± 0.9 | 26 (13.6) | 136 (71.2) | 29 (15.2) |
| Balance subscore (0–4 points) | 3.7 ± 0.7 | 3.7 ± 0.7 | 0.0 ± 0.8 | 21 (11.0) | 147 (77.0) | 23 (12.0) |
| 4-m usual gait subscore (0–4 points) | 4.0 ± 0.2 | 4.0 ± 0.2 | 0.0 ± 0.2 | 2 (1.0) | 186 (97.4) | 3 (1.6) |
| 4-m usual gait time (s) | 3.2 ± 0.7 | 3.2 ± 0.7 | 0.0 ± 0.5 | 84 (44.0) | 2 (1.0) | 105 (55.0) |
| Five Times Sit-to-Stand subscore (0–4 points) | 3.9 ± 0.4 | 3.9 ± 0.3 | 0.0 ± 0.5 | 10 (5.2) | 171 (89.5) | 10 (5.2) |
| Five Times Sit-to-Stand time (s) | 7.4 ± 2.2 | 7.2 ± 2.1 | –0.2 ± 1.9 | 106 (55.5) | 3 (1.6) | 82 (42.9) |
| Handgrip strength, right (kg) | 22.3 ± 6.6 | 21.8 ± 5.5 | –0.5 ± 3.0 | 117 (61.3) | 7 (3.7) | 67 (35.1) |
| Handgrip strength, left (kg) | 20.8 ± 6.1 | 20.4 ± 5.3 | –0.5 ± 3.2 | 104 (54.5) | 10 (5.2) | 77 (40.3) |
| Timed Up and Go (TUG) test (s) | 7.1 ± 1.9 | 7.2 ± 1.9 | 0.1 ± 1.1 | 81 (42.4) | 5 (2.6) | 105 (55.0) |
| 4-m maximum-pace gait time (s) | 2.6 ± 0.6 | 2.7 ± 0.7 | 0.0 ± 0.4 | 92 (48.2) | 6 (3.1) | 93 (48.7) |
Values are presented as mean ± SD or n (%).
Change was calculated for each participant as the 6-month follow-up value minus the baseline value.
Decrease indicates that the 6-month follow-up value was lower than the baseline value; no change indicates that the values were identical; and increase indicates that the 6-month follow-up value was higher than the baseline value.
The direction of change shown in this table does not necessarily indicate clinically meaningful improvement or worsening.
SPPB: short physical performance battery.
Spearman’s rank correlation analysis was conducted to examine bivariate associations between changes in the social function domain score (ΔSocial) and changes in physical function parameters over the 6-month period (Table 4). Δ4-m usual gait time (r=0.229, p=0.002) and Δ4-m usual gait subscore (r=−0.242, p=0.001) were significantly correlated with ΔSocial. In addition, ΔFive Times Sit-to-Stand time was weakly but significantly correlated with ΔSocial (r=0.149, p=0.040). No significant correlations were observed between ΔSocial and age, sex, ΔSPPB total score, Δbalance subscore, ΔFive Times Sit-to-Stand subscore, Δ4-m maximum-pace gait time, ΔTUG, or Δhandgrip strength (p>0.05 for all).
Table 4. Spearman correlations between changes in the social function domain score (ΔSocial) and changes in physical function parameters (n=191).
| Variable | r |
| Age | 0.100 |
| Sex | 0.095 |
| ΔSPPB total score | –0.010 |
| ΔBalance subscore | –0.049 |
| ΔFive Times Sit-to-Stand time (s) | 0.149* |
| ΔFive Times Sit-to-Stand subscore | –0.108 |
| Δ4-m usual gait time (s) | 0.229** |
| Δ4-m usual gait subscore | –0.242** |
| Δ4-m maximum-pace gait time (s) | 0.088 |
| ΔTimed Up and Go (TUG) (s) | 0.060 |
| ΔHandgrip strength, right (kg) | 0.064 |
| ΔHandgrip strength, left (kg) | 0.106 |
Spearman’s rank correlation coefficients were calculated. Δ indicates change over the 6-month period (follow-up minus baseline). *p<0.05, **p<0.01.
Multiple linear regression analysis was performed to examine whether changes in the 4-m usual gait time were associated with changes in the social function domain score in a regression model adjusted for age and sex (Table 5). As shown in Table 5, Δ4-m usual gait time was significantly associated with ΔSocial (B=0.620, SE=0.160, t=3.883, p<0.001), whereas age (p=0.123) and sex (p=0.310) were not significantly associated with ΔSocial. The overall model was statistically significant (F(3,187)=6.40, p<0.001), explaining 9.3% of the variance in the change in the social function domain score (R2=0.093, adjusted R2=0.079).
Table 5. Multiple linear regression analysis of factors associated with change in social function domain score (ΔSocial) (n=191).
| Variable | B | SE |
| Intercept | –1.497 | 1.055 |
| Δ4-m usual gait time (s) | 0.620*** | 0.160 |
| Age (years) | 0.020 | 0.013 |
| Sex (Male vs. Female) | –0.222 | 0.218 |
Model statistics:
R2=0.093, Adjusted R2=0.079. Δ indicates change over the 6-month period (follow-up minus baseline). Female was the reference category for sex. ***p<0.001.
DISCUSSION
In this longitudinal study, we examined whether within-person changes in physical function were associated with contemporaneous changes in the social function domain score among community-dwelling older adults participating in a municipal community program. The principal finding was that changes in 4-m usual gait time over the 6-month period were associated with changes in the social function domain score in a regression model adjusted for age and sex. In contrast, changes in several other physical performance measures, including balance, handgrip strength, TUG test, and SPPB total score, were not significantly associated with changes in the social function domain score.
Usual gait speed is widely recognized as an integrated indicator of the overall health status of older adults. Large cohort studies have shown that slower usual gait speed has prognostic value for disability, hospitalization, and mortality4, 10), and longitudinal evidence from Japanese community-based cohorts has shown an association between usual walking speed and all-cause and cardiovascular mortality11). As physical performance, including gait speed, reflects the integrated function of multiple physiological systems, it has been proposed as a pragmatic clinical “vital sign” in older adults12). In this context, the present findings are consistent with previous evidence by showing that within-person changes in 4-m usual gait time were associated with contemporaneous changes in the social function domain score.
Social frailty has been conceptualized as a multidimensional vulnerability characterized by reduced social participation, networks, and role engagement13), and longitudinal studies have shown a bidirectional relationship between physical and social frailty2, 3). The coexistence of physical and social vulnerabilities substantially increases the risk of disability and long-term care needs7, 14). While prior research has primarily focused on baseline predictors or categorical transitions, the present study adds to this literature by examining continuous change scores. Our findings suggest that short-term changes in usual gait time are associated with changes in the social function domain score at the within-person level.
The absence of comparable associations for several other physical performance measures warrants careful consideration. Balance, handgrip strength, TUG, and SPPB total score are well-established indicators of physical performance and adverse health outcomes15,16,17); however, these measures are generally assessed under standardized test conditions and may primarily reflect functional capacity in controlled settings12). In contrast, 4-m usual gait time is measured at a self-selected walking pace and may capture aspects of habitual mobility that are closer to everyday walking behavior. Mobility in older adults is a multidimensional construct influenced not only by physical capacity but also by cognitive, psychosocial, environmental, and economic factors18). Lower mobility is associated with lower levels of social engagement among older adults19), and greater walking confidence and lower energy cost of walking are associated with broader life-space mobility20). In addition, safe and stable walking has been described as a complex process involving interactions among neuromuscular, sensory, and cognitive functions21). Taken together, these findings suggest that the observed association between changes in 4-m usual gait time and changes in the social function domain score may reflect the relevance of self-paced walking performance to everyday mobility rather than a direct effect of walking performance on the social function domain score. From a clinical perspective, usual gait time may be a useful indicator when considering the relationship between everyday mobility and the social function domain score in community-dwelling older adults.
This study has several strengths, including its longitudinal design, relatively large community-based sample, and use of standardized physical performance measures. By focusing on change-to-change associations, this analysis provides information on within-person functional changes beyond cross-sectional associations. However, some limitations of this study should be acknowledged. First, the observational design precludes causal inferences, and the direction of the association could not be determined. Changes in the social function domain score may have influenced physical activity and walking performance, and residual confounding could not be excluded because the regression model was adjusted only for age and sex. Other physical performance variables, psychosocial factors, environmental factors, and baseline values may have influenced the observed association. Second, change-score analyses have methodological constraints, including dependence on baseline values and possible regression to the mean. In addition, potential ceiling effects should be considered, particularly for measures with high baseline scores, such as the SPPB total score and gait-related subscores. Third, the social function domain score was derived from a screening-based measure and may not capture the qualitative aspects of social relationships. The sample also predominantly consisted of older women participating in community activities, which may limit generalizability.
In conclusion, 6-month changes in 4-m usual gait time were associated with concurrent changes in the social function domain score among community-dwelling older adults. This association was observed in a regression model adjusted for age and sex. These findings suggest that usual gait time may be a useful indicator when considering the relationship between everyday mobility and the social function domain score in later life. However, the results should be interpreted as concurrent associations and not as evidence that changes in walking performance cause changes in the social function domain score.
Conference presentation
Part of this study was presented at the 12th Annual Meeting of the Japanese Society of Community-Based Comprehensive Physical Therapy.
Funding
The authors received no funding for this study.
Conflict of interest
The authors declare no conflict of interest.
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