Introduction: Frailty is associated with adverse outcomes, but few studies have determined associations between the frailty phenotype and measures of healthcare burden, including long-term care insurance (LTCI) costs, in older community-dwelling populations. Objective: The aim of this study was to examine the association between frailty status and subsequent LTCI costs in Japanese community-dwelling older adults. Methods: The prospective data were from a cohort study (National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes [NCGG-SGS]). The participants were community-dwelling older adults (mean age 71.8 years, women 50.7%) participating in an NCGG-SGS baseline examination held between August 2011 and February 2012 in Obu, Japan (N = 4,539). At baseline, we assessed the physical frailty phenotype using the Japanese version of the CHS criteria and categorized it as robust, pre-frail, or frail. We also ascertained care-needs certification and total costs using long-term care services in Japan’s public LTCI system during the 29 months. Results: During the 29-month follow-up period, 239 participants (5.3%) required the LTCI system’s care-needs certification and 163 participants (3.6%) used LTCI services. Participants classified as frail (odds ratio 5.85, 95% confidence interval 3.54–9.66) or pre-frail (2.40, 1.58–3.66) at the baseline assessment had an increased risk of requiring care-needs certification compared with robust participants. The mean total costs for LTCI services during the 29 months were ¥6,434 ($63.1) for robust, ¥19,324 ($189.5) for pre-frail, and ¥147,718 ($1,448.2) for frail participants (1 US dollar = 102 Japanese yen in July 2014). There were significantly higher costs associated with advancing frailty status. Individual frailty components (slowness, weakness, exhaustion, low activity, and weight loss) were also associated with higher total costs for using LTCI services. Discussion/Conclusion: Frail community-dwelling older adults had a higher risk of requiring the LTCI system’s care-needs certification and the subsequent total LTCI costs.

Frailty is a clinical condition characterized by the excessive vulnerability of an individual to endogenous and exogenous stressors [1]. The condition of frailty is gaining global attention as the population of older adults is increasing owing to rising life expectancy [2]. Frailty is associated with adverse outcomes such as increased mortality, hospitalization, falls, and limitations in activities of daily living (ADL) [3, 4]. Additionally, it would lead to admission to long-term care, resulting in an increased risk of disability [5, 6]. Therefore, frailty is a significant concern regarding the need for support or care certified by the Japanese public long-term care insurance (LTCI) system. In addition, longitudinal studies have examined the association between frailty and costs (e.g., in geriatric surgery and older adults with or without dementia) [7, 8]. However, further research should expand on these aspects.

Older adults are the primary users of healthcare services and account for the majority of healthcare costs [9]. In 2016, the percentage of people aged 65 years and older in Japan was 27.3%, the highest in the world [10]. In 2012, the Japanese LTCI system’s long-term care service costs were approximately 9 trillion yen (nearly 880 billion US dollars based on the exchange rate in 2014) and expected to double (i.e., 18 trillion yen) by 2025 [11].

Few previous studies have determined associations between the frailty phenotype and measures of healthcare burden, including LTCI costs, in older community-dwelling populations. A cross-sectional survey of German adults reported that frailty was associated with higher healthcare costs; specifically, weight loss and exhaustion, among the 5 symptoms of frailty, were significantly related to total costs [12]. However, estimates of costs relied on participant recall. Investigations of associations of frailty phenotypes and healthcare costs involved using a prospective design from the Study of Osteoporotic Fractures (SOF). The findings showed that frail community-dwelling older women had higher subsequent total healthcare costs [13]. This SOF, a prospective cohort study, analyzed relatively on a short term (during 12 months after baseline) follow-up data from well-functioning community-dwelling older white women.

Japan has the highest healthy life expectancy of the older adult population and well-being [14]. In 2013, Japan attained not only the world’s longest life expectancy of 80.1 years for men and 86.4 years for women but also the highest healthy life expectancy of 71.1 years for men and 75.6 years for women [15]. However, there is an approximate 9-year to a 12-year difference between healthy life expectancy and life expectancy, and it would be necessary to shorten the unhealthy period in late life. It is important to recognize that not all older adults present frailty, but the majority of older adults had certification of needed support in the LTCI because of frailty status, especially old-old people. A 7.9% prevalence of frailty among community-dwelling Japanese older adults has been presented by previous meta-analysis [16]. Those prevalence rates increase as age advances: 10.0% between 75 and 79 years, 20.4% between 80 and 84 years, and 35.1% for 85 years and older. Therefore, it is important to examine the association between frailty status and LTCI costs and also considering prevention strategies for controlling LTCI costs among community-dwelling older adults.

This prospective cohort study aimed to examine the association of frailty status with subsequent LTCI costs during the 29 months after a baseline health check in Japanese community-dwelling older adults. Moreover, the estimated costs for LTCI among adults aged 75 years and older were calculated in several models that assumed a decrease in frailty as adults aged ≥75 years in Japan will increase rapidly compared to adults aged between 65 and 74 years [17]. Therefore, this study would provide additional knowledge estimating LTCI costs concretely through prevention of frailty, especially among the old-old population. Understanding the associations between frailty status and future LTCI costs can provide supportive evidence for strategies to prevent or improve frailty status in the community.

Study Population

The selection of participants was from adults enrolled in a population-based cohort study titled “the Obu Study of Health Promotion for the Elderly (OSHPE)” [18], which is part of the National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes (NCGG-SGS) [19]. Recruitment of OSHPE participants was from Obu, a residential suburb of Nagoya, Japan. In 2015, the population of Obu city was approximately 89,000 and the aging rate was 21.1% (cf. Japan’s aging rate 26.6% in 2015). The main inclusion criterion was that participants needed to be 65 years or older at baseline. From the potential participant pool (n = 15,974), we excluded 1,661 individuals who were participating in another study, were hospitalized, were in residential care, or were already certified by the Japanese LTCI system as needing long-term care for disability. The remaining 14,313 individuals were invited to participate, and 5,104 ultimately participated in the first wave of the OSHPE assessment between August 2011 and February 2012 (response rate = 35.7%) [20]. Participants who had long-term care, who had cognitive impairment (Mini-Mental State Examination (MMSE) score <18), who were missing frailty assessments at the first wave of the OSHPE, and who died or moved to other area during the 29-month follow-up period were excluded. In the present study, we analyzed longitudinal data from 4,539 community-dwelling older adults who had participated in the first wave of the OSHPE, followed by the LTCI system.

The exclusion criteria were the need for support or care, certified by the Japanese public LTCI system; disability in basic ADL (self-feeding, personal hygiene and grooming, walking, climbing stairs, and bathing), and inability to undergo performance-based assessments (e.g., severe hypertension, balance impairment, or pain) during the first wave of the evaluation. Further, there was an exclusion of participants with a history of Parkinson’s disease, stroke, depression, Alzheimer’s disease, or those with MMSE scores <18 [18, 21]. Participants who died or moved to another city during the 29-month follow-up period were also excluded.

Participants were then followed up monthly for the next 29 months and monitored for inclusion in the LTCI system. Furthermore, to assess the eligibility for these benefits, the LTCI system conducts assessments on the requirement of the LTCI’s care-needs certification and the use of long-term care services. All participants gave their written informed consents.

Frailty Phenotype

We considered the characterization of the physical frailty phenotype by limitations of the following five conditions based on those used in Fried et al.’s [3] original studies: weight loss, exhaustion, low activity, weakness, and slowness. We considered participants who had none of these conditions to be robust, those with 1 or 2 conditions to be pre-frail, and those with 3 or more to be frail [3, 5]. The definition of physical frailty used in the present study has been provided in detail elsewhere (Japanese version of the CHS [J-CHS]) [5]. We based weight loss on the question “Have you lost 2 kg or more in the past 6 months?,” as used in the Kihon Checklist, a self-reported, comprehensive health checklist [22]; a response of “yes” indicated weight loss. The basis of exhaustion was on an answer of “yes” to the question “In the last 2 weeks, have you felt tired for no reason?,” which is also from the Kihon Checklist [22]. Further, we defined low activity levels as a response of “no” to the questions “Do you engage in moderate levels of physical exercise or sports aimed at health?” and “Do you engage in low levels of physical exercise aimed at health?” [18]. Weakness was defined as lower muscle strength assessed using grip strength, as measured with a Smedley-type handheld dynamometer (GRIPD; Takei, Niigata, Japan), with cutoffs of <26 kg for men and <18 kg for women [5]. The establishment of slowness was according to a predetermined cutoff (<1.0 m/s) [18].

Measurements

Demographic data, including age, sex, number of prescribed medications, and medical history, were recorded in face-to-face interviews by licensed nurses. We measured the participants’ height and weight and calculated BMI (kg/m2). The assessment of global cognitive function and depressive symptoms involved using the MMSE [21] and the 15-item Geriatric Depression Scale (GDS) [23]. Both MMSE and GDS-15 are widely used tools with favorable psychometric properties for older adults [24].

Outcome Measures and LTCI System

After the first wave of the assessment, participants were followed up monthly for 29 months and monitored for inclusion into the LTCI system or use of the LTCI care services. Japan implemented a mandatory social LTCI system on April 1, 2000 [25]. All Japanese citizens aged 65 and older are eligible for benefits (institutional and community-based services, but not cash) in cases of physical or mental disability.

The computer-aided standardized needs-assessment system used by the mandatory social LTCI system categorizes people into 7 levels of needs [25]. Therefore, to determine an individual’s level of nursing care need, a trained local government official visits the individual’s home and administers a questionnaire regarding the current physical and mental status (73 items in 7 dimensions; e.g., paralysis and limitation of joint movement, movement and balance, complex movement, conditions requiring special assistance, ADL/instrumental ADL, communication and cognition, and behavioral problems) and the use of medical procedures (12 items). The results of the questionnaire were then entered into the computer to calculate the applicant’s standardized scores for the 7 dimensions of physical and mental status and the estimated time for 9 categories of care (grooming/bathing, eating, toileting, transferring, eating, assistance with instrumental ADL, behavioral problems, rehabilitation, and medical services), after which we assigned the care-needs level based on the total estimated time taken for care. After this, the Nursing Care-Needs Certification Board, which comprises physicians, nurses, and other experts in health and social services, reviews and confirms the care-needs level [25].

From the LTCI dataset, we obtained cost data regarding information about using insured services, including usage for either home-based or community-based and institutional care services, such as home visits, day care, short stays, and residential or in-facility services of the LTCI system. In general, 10% of these costs are co-payments (the municipality, which acts as an insurer, pays 90%). However, there is an upper limit to the amount of monthly insurance benefits, which differs depending on the required level of care [26]. The data regarding LTCI costs in this study were only for LTCI care covered by insurance; the data did not include expenses that were not covered by insurance, such as food, housing, and diaper expenses.

People with LTCI certifications and who need (levels 1–5) or require support (level 1 or 2) can use LTCI services. Those certified as requiring higher levels of care can use more LTCI services through insurance coverage. The cumulative cost of such care in the following cases is zero: deceased individuals who did not have functional disabilities, respondents who did not have proper certification, and nonservice users. This study did not apply a societal perspective and only focused on formal care costs corresponding to LTCI.

In Japan, the proportion of LTCI users was <5% in older adults 74 aged years and younger, and >10% in those aged 75 years and older [27]. Furthermore, this proportion was over 20% in older adults aged 80–84 years and over 40% in those aged 85–89 years according to data from the Ministry of Health, Labour and Welfare in 2013. Additionally, the ratio of young-old (65–74 years) and old-old (75 years and older) was approximately 1:1 in 2015. This ratio is expected to be 1:1.5 in 2025 [28]. Therefore, evaluating LTCI costs in older adults aged 75 years and older will be required in Japan.

Statistical Analysis

We classified the participants into robust, pre-frail, and frail groups based on the baseline status of physical frailty and compared the characteristics by 1-way ANOVA or the χ2-test. We tested the associations between requiring the LTCI’s care-needs certification and using long-term care services and baseline physical frailty status, sex, age-group, and subitems of physical frailty using χ2-tests. The mean cost per person for LTCI services during the 29-month follow-up period was calculated, and the differences in baseline status including physical frailty status regarding LTCI service costs were tested using Mann-Whitney U tests. Generalized linear models were used to examine the independent association between future LTIC costs and baseline frailty status. Potential confounders included in the multivariate models were age, gender, prescribed medications, BMI, MMSE, and GDS.

Logistic regression models were also used to analyze the associations between baseline frailty phenotype and the requirement of care-needs certification and LTCI services. The base models included age and sex. We further adjusted the multivariable models for prescribed medications, BMI, MMSE score, and GDS. Adjusted odds ratios (ORs), 95% confidence intervals (CIs), pseudo R2 for the requirement of care-needs certification, and LTCI services were estimated.

We estimated the future costs for LTCI services in cases including 10,000 and 100,000 older adults ≥75 years without a disability. The estimations included if frailty and pre-frailty prevalence were not changed (model 1), if there was a decrease in frailty prevalence by 3% (model 2), and if there was a decrease by 3% in both frailty and pre-frailty prevalence (model 3).

The prospective study cohort included 4,539 community-dwelling adults with a mean age ±standard deviation of 71.8 ± 5.3 years (Table 1). The prevalence rates of frailty and pre-frailty at baseline were 7.1 and 50.1%, respectively. Of 2,238 men, 137 (6.1%) presented frailty, and of 2,301 women, 183 (8.0%) presented frailty. Significant differences in baseline characteristics, including age, sex, education years, BMI, and prescribed medications, were found among physical frailty status. The baseline MMSE and GDS scores were also significantly different among physical frailty status, with lower MMSE scores and higher GDS scores in participants’ frailty (Table 1).

Table 1.

Baseline characteristics of participants according to frailty phenotype

 Baseline characteristics of participants according to frailty phenotype
 Baseline characteristics of participants according to frailty phenotype

During the 29-month follow-up period, 239 participants (5.3%) required the LTCI system’s care-needs certification and 163 participants (3.6%) used LTCI services (Table 2). We found the highest incidence rate of the requirement for the LTCI system’s care-needs certification in participants with frailty (26.3%) compared to those with pre-frailty (5.6%) and those with robustness (1.6%). Older women (6.2%) showed a significantly higher rate of requiring care-needs certification than older men (4.3%). All frailty conditions were associated with a higher risk of requiring care-needs certification. In the generalized linear models, the baseline frailty status was significantly associated with future LTCI costs (standardized β coefficient = 0.07, p < 0.001) after adjusting for all variables. We presented the associations between the frailty phenotype and the requirement of care-needs certification and usage of long-term care services during the 29-month follow-up in Table 3. Participants classified as frail (OR 5.85, 95% CI 3.54–9.66) or pre-frail (2.40, 1.58–3.66) at the baseline assessment had an increased risk of requiring care-needs certification compared to robust participants in the logistic regression model, which included age, sex, prescribed medications, BMI, MMSE score, and GDS-15 as covariates. The incidence rates for using long-term care services in participants with frailty (OR 5.66, 95% CI 3.05–10.53) and pre-frailty (OR 2.70, 95% CI 1.59–4.59) were higher than those with robustness, as observed in the multivariable model.

Table 2.

Requirement of care-needs certification, long-term care services, and long-term care costs

 Requirement of care-needs certification, long-term care services, and long-term care costs
 Requirement of care-needs certification, long-term care services, and long-term care costs
Table 3.

Associations between frailty phenotype and the requirement of care-needs certification and using long-term care services in Japan’s public LTCI system during a 29-month follow-up

 Associations between frailty phenotype and the requirement of care-needs certification and using long-term care services in Japan’s public LTCI system during a 29-month follow-up
 Associations between frailty phenotype and the requirement of care-needs certification and using long-term care services in Japan’s public LTCI system during a 29-month follow-up

The mean total costs for LTCI services during the 29 months were ¥6,434 ($63.1) for robust, ¥19,324 ($189.5) for pre-frail, and ¥147,718 ($1,448.2) for frail participants (1 US dollar = 102 Japanese yen in July 2014) (Table 3). There were significantly higher costs according to advancing frailty status (p < 0.001). There were no significant differences in the mean total costs for LTCI services between older men and women (p = 0.208). Special frailty conditions (slowness, weakness, exhaustion, low activity, and weight loss) were also associated with higher total costs for using LTCI services.

Tables 4and5 present the total costs of LTCI services among older adults aged 75 years and older and the es­timated costs in case of decreasing prevalence of frailty and pre-frailty in the population of those aged 75 years and older. In this study, we included 1,253 adults aged ≥75 years. Among those participants, prevalence rates of frailty, pre-frailty, and robust at baseline were 16.4, 55.3, and 28.3%, respectively. The total LTCI service cost during the 29-month follow-up period was ¥86,766,991 ($850,657). When we replaced the same prevalence and incidence rates in 10,000 older adults (≥75 years), the estimated total costs for LTCI services would reach ¥691,652,790 ($6,780,910) for 29 months (model 1). However, if the prevalence of frailty decreased by 3% (from 16.4 to 13.4%), the estimated total costs for LTCI services reduced to ¥640,513 290 ($6,279,542), which indicated approximately ¥51,139,500 ($501,368) decrease (model 2). Moreover, if the prevalence of both frailty and pre-frailty decreased by 3% (from 16.4 to 13.4% in frailty and from 55.3 to 52.3% in pre-frailty), the estimated total costs for LTCI services indicated ¥67,343,700 ($660,232) decrease (model 3). When we applied these estimations to the case that included 100,000 older adults (≥75 years), estimated reducing costs for LTCI services increased 10 times, ¥511,395,000 ($5,013,676) decrease, and ¥673,437,000 decrease ($6,602,324), respectively.

Table 4.

Total costs (Japanese yen) of LTCI services among older adults aged 75 years (n = 1,253)

 Total costs (Japanese yen) of LTCI services among older adults aged 75 years (n = 1,253)
 Total costs (Japanese yen) of LTCI services among older adults aged 75 years (n = 1,253)
Table 5.

Estimated costs (Japanese yen) among older adults aged 75 years and older

 Estimated costs (Japanese yen) among older adults aged 75 years and older
 Estimated costs (Japanese yen) among older adults aged 75 years and older

The current prospective study conducted for 29 months indicated that older individuals with physical frailty had an approximate 6-fold higher risk of requiring care-needs certification than those with robustness. It is well known that frailty is associated with an increased need for care. The current study provides additional knowledge estimating LTCI costs concretely through prevention of frailty. Especially, the associations between frailty status and future LTCI costs would be clearer among the old-old population. Older individuals with frailty had higher costs for LTCI services than those without frailty; we established an approximate ¥140,000 ($1,380) difference in mean costs for LTCI services between older adults with frailty and those with robustness. In particular, there were more considerable differences between frailty and robustness among older adults aged 75 years and older, which was approximately ¥197,000 ($1,930) for the mean costs of LTCI services.

Frailty status in community-dwelling older adults is associated with poor health outcomes. The impact of frailty on the risk of requiring care-needs certification in the LTCI system is more significant with advancing age [5]. Therefore, we expected the remarkable effects of frailty status on increased costs for LTCI services. The current prospective study indicated that frailty status required higher LTCI costs; thus, we suggest the necessity of preventing frailty.

The frail group presented older age and fewer years of education than other groups. Generally, advancing age is considered the most influential factor for frailty. In Japan, compulsory years of schooling increased from 3 to 6 in 1907. The educational system was transformed in 1947 following the end of World War II and compulsory schooling augmented to 9 years [29], increasing the years of education in adults. Thus, negative relationships between advancing age and education years are inferred among the current older population in Japan. Fewer years of education, as well as advancing age, may be associated with frailty status since educational attainment can affect mortality and other health outcomes [30].

Previous studies have shown that individuals with lower MMSE scores and higher GDS scores indicating depressive symptoms had a greater risk of long-term care need [31, 32]. In this study, even after adjusting those scores, >5 times higher ORs for requirement of care-needs certification and using long-term care services were found. Although further studies are needed, the combined status of physical frailty with cognitive impairments and/or depressive symptoms may have greater impacts on future long-term care costs.

A recently published systematic review and meta-analysis, including 5 studies, indicated that although there was a high degree of heterogeneity, both pre-frailty and frailty were associated with significantly higher healthcare costs when than robustness [33]. The current prospective study involved only LTCI services costs to examine the associations between frailty status and future healthcare costs. Older adults who obtain care-needs certification may have increased medical expenses such as hospitalization, outpatient care, and pharmacy [13, 34]. Among community-dwelling adults, the prevalence of self-reported hospitalization in the past year was higher with a higher degree of frailty [3, 35]. The increased costs for health care, including medical care and long-term care among older adults, may differ according to the care policy and insurance system. In the older adult population, community-dwelling older adults with geriatric syndromes that are clinical conditions not necessarily attributed to a specific, isolated underlying disease including frailty may increase. Therefore, preventing frailty may lead to a reduction in care cost burden.

There is a need for an economic evaluation of frailty prevention and improvement strategies. As well, there is a review of the effectiveness of interventions in older adults with frailty [36]. However, only a few studies have performed economic evaluations. A previous community-based 12-month multifactorial intervention study, including 241 community-dwelling older adults with frailty in Sydney, provided better value in multifactorial, interdisciplinary intervention targeting identified frailty characteristics for money than usual care [37]. A single-blind, 3-armed, cluster-randomized controlled trial with a 12-month follow-up to determine the cost-effectiveness of a proactive, integrated primary care program indicated that an active screening intervention had a high probability of being cost-effective than the usual care [38]. The results of a multicenter randomized controlled trial suggest that inpatient or outpatient geriatric evaluation and management reduced the degree of functional decline at discharge among patients assigned to inpatient units for geriatric assessment and management, and improvements in mental health among those assigned to outpatient clinics for geriatric evaluation and management, without an increase in the overall cost [39]. As such, it would be possible to conduct interventions for frailty prevention and improvement while maintaining the cost burden in the community.

Several intervention studies in older adults with frailty or pre-frailty have shown to be effective in preventing the progression of pre-frailty and frailty [36]. Even available evidence mostly comes from samples of community-dwelling older adults, and there was an observation on applicable rates of spontaneous reversion across the available studies, with 13.8–44.6% of frail participants reverting to pre-frailty or robustness [40]. The current prospective study indicated that there is a cost-benefit regarding future LTCI costs in robust and pre-frail older adults of approximately ¥200,000 ($1,960) compared to those with frailty. Therefore, prevention and improvement strategies for frailty among community-dwelling individuals must be useful in the dimension of economic benefit in the aged population. These impacts will be remarkable for the aged population. For instance, in the case of 10 million older adults aged 75 years and older (e.g., 18.5 million people in Japan), if the prevalence of both frailty and pre-frailty decreased by 3%, the estimated total costs for LTCI services were minus ¥67,343,700,000 (approximately $660,000,000). Additionally, there is a need for more knowledge about intervention strategies that are effective, feasible, and cost-effective for frailty [41].

We conducted the current study in a specific city in Nagoya, Japan. The LTCI services include home (e.g., home help services, visiting nurse services, visiting bathing services, and visiting rehabilitation services) and institutional (e.g., nursing home, health service facility for the aged, and rehabilitation facility), and geriatric ward (under the LTCI scheme) services [26]. LTCI service users may not receive similar services throughout Japan, and several factors, such as social and medical factors, may affect the type of LTCI services [42]. Unfortunately, the type and frequency of long-term care services used by participants were not assessed in this study. Understanding the most frequently used long-term care services and their background might show in-depth schemes for estimating the costs related to dependency care. Approximately 10% of the baseline sample was excluded based on criteria such as death or moving to other areas during the follow-up period. Although survival effects cannot be denied, we assume that the effects of panel attrition were relatively low. Additional analyses will be needed to clarify the effects of panel attrition in future studies.

Although we believe that the current prospective study has several strengths, such as analyzing public data from the LTCI system with longitudinal data, potential limitations are noteworthy. This study used economic data and examined only LTCI service costs (i.e., formal care costs). The establishment of the Japanese LTCI system was to shift the burden of family caregiving to society, shift cost-sharing via an insurance premium system, and integrate long-term medical care and welfare services [10]. Nonetheless, older adults who require care-needs certification will need support and care from family caregivers (i.e., informal care costs) and increase medical costs for their health care. Unfortunately, economic status such as participants’ income or co-payment was not included in this study. In this regard, there may be slight impacts of participants’ monthly income when using care services, since Japan has a national health insurance program that participants can use for care services bearing 10% of care services fees in Japanese long-term care insurance. Additionally, the current study involved only older adults who participated in the first wave of the OSHPE assessment held in the community. Thus, it is not possible to generalize the current findings to institutionalized individuals. Typical psychological functioning measures of MMSE and GDS-15 were included as covariates in the logistic regression model. However, far more exhaustive covariates should be considered (e.g., psychometric characteristics).

Community-dwelling older adults with physical frailty had a higher risk of requiring the LTCI system’s care-needs certification. Older adults with physical frailty had higher costs for LTCI services than those without frailty; we established an approximate ¥140,000 ($1,380) difference in mean costs for LTCI services between older adults with frailty and those with robustness. Frailty prevention strategies among community-dwelling older adults may be needed to prevent not only future functional decline but also an increase in long-term care costs.

We thank all participants and the Obu municipal government for their help with participant recruitment.

This study was approved by the Ethics Committee of the National Center for Geriatrics and Gerontology (Approval Nos. 523, 602-2, and 791). We obtained written informed consent from all participants before their inclusion in the study.

The authors declare no conflicts of interest.

This work was supported by the National Center for Geriatrics and Gerontology (Research Funding for Longevity Sciences) (Grant Nos. 22-16, 26-33, and 20-1).

Hyuma Makizako and Hiroyuki Shimada conceived and designed the study. Hyuma Makizako performed the analyses and drafted the manuscript. Kota Tsutsumimoto, Keitaro Makino, Sho Nakakubo, Hideaki Ishii, and Takehiko Doi prepared the data. Hiroyuki Shimada, Kota Tsutsumimoto, Keitaro Makino, Sho Nakakubo, Hideaki Ishii, and Takehiko Doi revised the manuscript. All authors participated in interpreting the results. All authors had full access to the data and are guarantors for the study.

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