Community Health and Longevity Project

Abstract

This project began in April 2017 with a survey of people who have achieved healthy longevity with the aim of preventing people from becoming bedridden and improving the health of local residents. The purpose of this survey was to contribute to the achievement of healthy longevity among older adults. We analyzed the current status of those who had achieved healthy longevity, aged 90 and over, living in Nonoichi City from qualitative and quantitative data. As a result, we have gradually been able to better understand the factors related to the achievement of healthy longevity, including (1) lifestyle history, (2) the assessment of cognitive functions, (3) frailty status, and (4) daily living functions. These results were published at several conferences in 2018 and 2019. Furthermore, we prepared a leaflet containing “four suggestions for living a long and healthy life,” which uses the results of previous surveys as evidence and promotes health promotion and care prevention activities for local community residents.

1. Introduction

According to World Health Organization (hereafter, called WHO), Japan has the highest life expectancy in the world in 2019 and the average life expectancy (84.3 years old) in Japan increased up by 5 years in the past 20 years. Healthy life expectancy (hereafter called, HALE) is a new index of life span WHO proposed. It is the period excluding “period of long-term care need such as bedridden state or dementia” from “average life expectancy.” Because the average life expectancy relates to HALE, usually counties, which have high rates of the average life expectancy, have high rates of HALE, too. However, differences between HALE and the average life expectancy in Japan were still more than 10 years despite that HALE increased up to 74.1 years [1].

In Japan, a social insurance program as a system supporting the elderly in need of nursing care and their family by the entire society started since 2000. According to “Report on insured long-term care service business (2018)” in Ministry of Health, Labour and Welfare, certification rates of needed support and long-term care in young-old were about 10%, but the rates in old-old were over 30% [2]. In the past 20 years, total cost of care insurance has been increasing every year [3]. It should be said that it is really difficult to continue this system as is. Therefore, it is necessary to establish the system that can function for additional extension of HALE in addition to the average life expectancy in the region and to restrain care costs. Japanese government sets “extension of HALE exceeding the average life expectancy as one of the growth strategy and aims for 3 years over extension of HALE by 2040.” Fortunately, the elderly over 100 years old(centenarians) are increasing rapidly in our country, Japan, and the number of them went up from 153 people in 1973 to over 80,000 in 2020 [4]. Until 90 years old, they are not only long-lived but also active, and their degree of independence is high in daily life. Therefore, they can be a model of healthy longevity.

In surveys aiming at the elderly in various districts, the percentage of the centenarians living an independent life ranges from about 15 to 40% [4, 5, 6]. About 97% of the centenarians had some intractable diseases as physical features, but they had a low prevalence of diabetes [7]. In addition, the analysis from multiple viewpoints was conducted such as relating a low of inflammatory maker to a high of cognitive functions and activities of daily living [8], the relationship among chewing power and walking speed, cognitive functions [9, 10, 11]. As for lifestyles, 70% of them consciously ate three meals a day with regularity since middle age. On the other hand, as for a fitness habit around 70 to 80 years old, the rate of doing it almost every day and the one of doing it rarely were 40% each [8]. Therefore, the association between the fitness habit and HALE was not cleared. In the mental side, a subjective sense of happiness was not decreased and even their physical functions were not declined [12]. Because objectively oldest-old adjusted psychologically to difficult situations by seeking an existential meaning and value [13], it can be said that they had a power to feel a sense of happiness and a flexible ability to respond toward various changes. Besides, having hobbies and taking part in recreational activities related to mental stability: living the independent life and maintenance of cognitive functions [4, 6, 14]. Hence, it is important to have circumstances they can be active for healthy longevity.

The factor of community level, “circumstances” such as economy and society, had a great impact on health [15]. It can be said that whether or not the area has strong social capital is the important factor. In this project, the authors wanted to clarify the capital in preparation for healthy longevity based on regional characteristics. Sharing of the capital preparing for health and longevity of local elderly people in collaboration with municipality can be used for making care prevention plans suiting for the area. Incidentally, the number of the centenarians has already reached to 919 of which is over the national average per capita in Ishikawa where population ratio of young people is high now.

2. Objective

The purpose of the project was to investigate main items assuming casual connection with healthy longevity aimed at achievers of health and longevity. As a result, secrets of healthy longevity were analyzed for the elderly living the area, and using them to help accomplishment of the elderly’s healthy longevity.

3. Methods

3.1 Survey area: nonoichi city, ishikawa prefecture, japan

Nonoichi City is located in the center of Ishikawa Prefecture and the northeast of the alluvial fun of Tedori river blessed with fertile land and groundwater of good quality. The area of Nonoichi City is 13.56 km²; the city has many commercial facilities and the excellent traffic network, and it is said that Nonoichi City is easy to live. Historically, Honmachi district the old Hokkoku-Kaido road is passing through was once-flourishing as a post station in Edo era. There currently remain houses as national important cultural properties and buildings with history as cultural properties designated by the city in Honmachi district.

The population of Nonoichi City at the time of the survey (September 2018) was 52,512(male: 26536, female: 25976) in total. The ration of population by three categories of age was follows. The young population (0 to 14 years old) was 19.3%; the productive population (15 to 64) was 64.5%; and the elderly population (over 65) was 19.3%. Because the population around the age of 20 is especially great, hence there are two universities within the city, and Nonomura City has the lowest aging rate in Ishikawa. However, Nonoichi City is expected to be the city where aging will advance rapidly because people immigrating into out-of-town new towns become the elderly at once. In “long-term visions of revitalization of Nonoichi City” [16] made in fiscal 2020, it is estimated that the population of the city will reach its peak in 2040 and be declined slowly afterward. In doing so, it is also estimated that Nonoich City will be super-aging society around 2020 and the productive population will be greatly declined with the elderly population growth.

3.2 Survey framework

This project tried to find factors of the accomplishment of healthy longevity via “health surveys by interviews”: “examination of frailty and fitness” and “surveys of dementia and activities of daily living: studies of ADL.”

The targeted area was Nonoichi City in Ishikawa Prefecture. The subjects of the survey were the elderly over 90 years old who could communicate and live in the independent life. With the introduction from Care and Longevity division in Nonoichi city hall and care managers in the city, we gained their approval of participating the survey.

3.3 Ethical considerations

This project was conducted with the approval of Kinjo university research ethics review board (Informed number 29–14).

4. Interviews health surveys by interviews

4.1 Purpose

As factors about health and longevity, it is said that physical health degree: mental health degree, characters, circumstances, family environments and generic factors, etc., are compositely related. The purpose of this survey was to grasp physical aspects, personal ones, familial ones, social and environmental ones of the oldest-old and the centenarians, and to find the factors related to healthy longevity.

4.2 Methods

Period: Between May 2017 and September 2018.

Interviews: Visiting the subject’s residence (house or nursing facility), the interview was conducted based on hearing from each one subject by two or three researchers (including students) using questionnaires. At the interview, the family, officials in charge in Care and Longevity division and long-term care specialists in charge sat with the subjects as desired. The interview was also done with the family and the specialists if communication with the subjects was difficult. The time of the interview was about 40 to 60 minutes considering burdens of the subjects. In the construction of researchers, one person (teacher) became the interviewer and one or two persons (student) became recorders. The contents of the interviews were recorded with the approval of the subjects before by use of IC recorder.

4.3 Survey items

An inquiring question was “How do achievers living in the independent life live or have their creed about daily lives?” Along this question, semi-structured interview was conducted about four aspects such as 1. physical factors: 2. personal ones: 3. familial ones, and 4. social and environmental ones.

4.4 Specific question items

1. Physical factors: Medical history, current treatment and medication situations, swallowing condition, dental status, the presence or absence of dysphagia, etc.

2. Personal factors: Fitness habits, health behaviors, how to spend a day, sleeping condition, the presence or absence of appetites, the presence or absence of likes and dislikes, excretion condition, character, hobbies, purpose of life and beliefs.

3. Familial factors: Health conditions or age of death of parents and siblings; family structure.

4. Social and environmental factors: Academic background, career, residence, the environment they have been lived, utilizing medical and care services, usage situation of social sources, relationship and social relations, etc.

4.5 Methods of analysis

Descriptive statistic was done by interview items about the features of achievers of healthy longevity. Besides, qualitative and inductive analysis was conducted with creeds related to the life of the achievers. Descriptions such as thoughts, values, and persistence about lives were extracted and encoded from the contents and verbatim reports of the interview. Considering semantic contents by sex, similar codes were collected sub-categorized. After that, sub-categories excluded separately were integrated and categorized.

5. Examination of frailty and fitness

5.1 Purpose

Aging and various diseases cause reduction in skeletal muscle mass and muscle weakness, and brought a decline of the ability to active in daily life and quality of life (QOL). These conditions are defined as sarcopenia and have a great influence on current HALE of Japan. According to previous studies, it is reported morbidity of sarcopenia in the elderly over 65 living in Japan was 11.5% in males and 16.7% in females [17]. However, there are few data about the oldest-old over 90 and the centenarians over 100 in Japan. Sarcopenia precedes frailty showing frail states of the elderly. To extend HALE from the aspects of motor functions, it is vital to prevent sarcopenia and keep good motor functions, and not to make the frail state. Hence, the purpose of this survey was to investigate current situations about frailty and sarcopenia in the oldest-old and the centenarians living in Ishikawa via measurement of muscle mass: strength, walking ability that become components of sarcopenia, and survey about current status of sarcopenia.

5.2 Methods

Subjects of this examination were oldest-old over 90 living in Nonoichi City in Ishikawa Prefecture who could be measured about the motor functions in the “health surveys by interviews” antecedently done. In addition, the subjects included the ones who could only take one of the measurement in the “health surveys.”

5.3 Survey items

Sarcopenia is defined as reduction in the skeletal muscle mass, muscle weakness, and decreasing gait speed. Therefore, measurement of the skeletal muscle mass and circumference of limbs for the reduction on the muscle, the measurement of grasping power for the muscle weakness, and the measurement of walking speed for decreasing the speed. As for physical frailty, Short Physical Performance Battery (SPPB) was measured.

5.4 Details of measuring items and specific measuring methods

1. Measurement of skeletal muscle mass: Skeletal muscle mass (SMM) is the total amount of skeletal muscle inside the body. Body constituent analyzer, InBody430 (made in InBody Japan Co., Ltd., Tokyo) was used to measure. This was done safely with observing by the tester on their side or on their back.

2. Measurement of circumference of lower limbs: Max abdominal muscle of lower limbs was measured to know the degree of muscle atrophy. Using measuring tapes, the measurement was conducted on the bed or sitting on the chair. Permission of undressing was gained verbally if the exposure of the skin was necessary.

3. Measurement of grasping power: Grasping power was measured in a sitting position by the use of grip dynamometer. Making a team of two persons, one person supported the maintenance of sitting position and another one examined. The grip dynamometer was Smedley-type hand dynamometer (T.K.K.5401, made in Takei Scientific Instruments Co. Ltd.) using general physical test.

4. Measurement of walking speed: The measurement was conducted for only the subjects who could walk. Whether or not they can walk was judged by interviews or checking with the subjects or their family by physical therapist. The places they walked were corridor in house or nursing facility. They walked a distance of five meters without running.

5. Measurement of Short Physical Performance Battery (SPPB): SPPB is a test battery that tests balance and walking functions, and five-repetition sit-to-stand test compositely. SPPB evaluates physical frailty by total 12 points (four points for each test). The measurement of balance and walking functions, and five-repetition sit-to-stand test were conducted with observation by the helper beside them.

6. Surveys of dementia and activities of daily living: studies of ADL

6.1 Purpose

It is known that cognitive functions of the centenarians relates to the activities of daily living (hereafter, called ADL), physical functions, and social life [18]. To assist accomplishment of HALE, surveys of cognitive functions and ADL were done aimed at the elderly.

6.2 Methods

The subjects of the survey were the elderly who could be subject to the survey based on conditions of communication of “health surveys with interviews.” Hearing from the subjects or their family was conducted. Besides, the subjects included the ones who could only take one of the measurement in the “health surveys.”

6.3 Details of items of measurement and specific measuring methods

1. Measurement of MMSE (Mini-Mental-State-Examination):

   It is the examination of cognitive functions. The total score is 30 points, and there are 11 items such as orientation: memorial power, calculation ability, linguistic competence, and special perception. If possible, the subjects took a sitting position and answered questions of the researchers (the requiring time of measurement was about 10 minutes).

2. Measurement of NM scale (Nishimura-type mental state scale for the elderly): It is the examination about cognitive functions. Seeing practical mental functions (conditions of dementia) of the elderly and dementia patients in daily life from various viewpoints, NM scale is a behavior rating scale that scores and evaluates the conditions. Using N-ADL (Nishimura’s Activities of Daily Life scale for the elderly) concurrently can capture the practical functions comprehensively in the aspects of daily life.

   The items are (1) housework and putting affairs, (2) interests and interaction increasing motivation, (3) communication, (4) memorization, and (5) orientation. Each item is 10 points, and the total score is 50 points. In the case of the subject being bedridden state, the score of (3) communication, (4) memorization, and (5) orientation is 30 points in total. The definition of bedridden state is defined as the persons who are under one point in “walking and sitting up in bed” in N-ADL. The interview was done with the subjects and their family about each items (the requiring time to measure was about 7 minutes).

3. Measurement of N-ADL:

   It is the examination about ADL. The items are (1) walking and sitting up in bed: (2) living area, (3) wearing and undressing, (4) feeding, and (5) excretion. Each item is 10 points, and the total score is 50 points. The interview was done with the subjects and their family about each items (requiring time to measure was about 7 minutes).

4. Measurement of BI (Brthel Index, functional assessment):

   It is the examination of ADL. It evaluates ADL on “self-help,” “partial assistance,” and “total assistance.” The items are (1) meals: (2) moving from wheelchair to bed, (3) “bathing,” (4) adjusting clothes, (5) bathing, (6) walking, (7) stepping the stairs, (8) changing clothes, (9) control of defecation, and (10) control of urination. There are 10 items in total. The total score is 100 points. The interview was done with the subjects and their family about each items (the requiring time to measure was about 6 minutes).

5. Measurement using cognitive functional balancer Pro, A2101 made in LEDEX Co. Ltd., Tokyo:

   In the case of obtaining the subject’s consent for additional research, the examination of cognitive functions was done another day by visiting their house again. In the examination, the cognitive functional balancer Pro was used. It is a device that can evaluate easily with a touch-screen computer. Twelve kinds of tasks such as orientation, visual search, and memorizing cards were done, and five aspects of cognitive functions such as planning ability, memory, attentiveness, orientation, and spatial ability were assessed. If possible, the subjects took a sitting position and answered the questions. If it was difficult to operate by fingers, researchers operated the computer instead of the subjects (the requiring time was about 30 minutes).

7. Results

7.1 Interviews health surveys by interviews

1. 2. Features of achievers of healthy longevity

Attributes of the subjects are shown in Table 1. The subjects were 27 elderly people (males were 6, and females were 21). Residents living at home were 19, and the ones of nursing home were 8. As for the degree of care needed, there were two subjects with frailty: one with support care level 2, seven with nursing care level 1, four with nursing care level 2, four with nursing care level 3, and 8 without any problem (a good condition). Although everyone saw a doctor regularly with some diseases, they could do supervised administration by supports, etc. Living conditions of the subjects are shown in Table 2. Twenty-five subjects (93%) cleaned their denture and had a good appetite without having likes and dislikes. Everyone went to the washroom themselves and 17 subjects (63%) slept well (Table 2). The subject’s personal history is shown in Table 3. Nine subjects had a very good childhood health condition: 11 subjects had a good one, three subjects had a sort of bad one, and one subject had a bad one. Nineteen subjects (70.4%) had a work experience. Eight subjects (30%) felt a strong fulfillment in the current life; 17 ones (63%) felt a fulfillment, and 24 ones (88%) had a hobby. The characteristics of the achievers of health and longevity from the survey were compiled below:

1. About 70% of the subjects had a good childhood health condition.

2. 80% of them saw a doctor regularly, but they could supervise administration.

3. Their denture was cleaned, and their oral condition was good.

4. They had a good appetite without having likes and dislikes.

5. They could do excretion themselves.

6. The felt fulfillment in the current life.

1. 2. Creeds related to lives of achievers of health and longevity

Sex
	Men	6	22.2
	Women	21	77.8
Age
	90–94	12	44.4
	95–99	14	51.9
	100-	1	3.7
Residence
	Home	19	70.4
	Nursing home	2	7.4
	Group home	2	7.4
	Assisted living residence	2	7.4
	Fee charging old people’s home	2	7.4
Care-level
	Frailty	2	7.4
	Requiring help 2	1	3.7
	Long-term care level 1	7	26.0
	Long-term care level 2	5	18.5
	Long-term care level 3	4	14.8
	No certification	8	29.6
Proportion of users by home care service (multiple answer)
	Prevention of long-term frailty service	4	14.8
	Senior Day Care Center	11	40.7
	Home-visit long-term care	4	14.8
	Home-visit nursing	2	7.4
	Home-visit rehabilitation	1	3.7
	Not use	7	26.0
Activity of Daily Living(n = 9)
	Self-support	1
	J2	1
	A1	2
	A2	5
Hospital visit
Yes		22	81.5
Causes of hospital visits (multiple answer)
	Hypertension	13
	Diabetes	3
	Herat disease	5
	Articular disease	9
	Constipation	5
	Gastrointestinal disease	3
	Respiratory disease	3
	Cancer	2
	Other causes (eye disease, skin disease, etc.)	13
No		2	7.4
Unknown		3	11.1

Table 1.

Participant characteristics n = 27.

Excretion behavior
	Self-support	26	96.3
	Partial assistance	1	3.7
Sleep conditions
	Good	17	63.0
	Insufficient	4	14.8
	Unknown	6	22.2
Appetite
	Good	25	92.6
	No	2	7.4
Likes and dislikes
	Yes	2	7.4
	No	25	92.6
Denture
	Yes	23	85.2
	No	3	11.1
	Unknown	1	3.7
Denture conditions
	Very good	8	29.6
	Good	7	26.0
	Slightly poor	8	29.6
	Poor	0	0.0
	Unknown	4	14.8
Regular check of denture
	Yes	7	26.0
	No	8	29.6
	Unknown	12	44.4
Dry mouth symptoms
	Yes	0	0.0
	A little	1	3.7
	No	22	81.5
	Unknown	4	14.8
Difficulty of swallowing
	Yes	0	0.0
	A little	1	3.7
	No	24	88.9
	Unknown	2	7.4
Choke up(Subjective experience)
	Yes	0	0.0
	Sometimes	1	3.7
	No	24	88.9
	Unknown	2	7.4

Table 2.

Characteristics of life and oral functions n = 27.

Childhood health status
	Very good	9	33.3
	Good	11	40.8
	Slightly poor	3	11.1
	Poor	1	3.7
	Unknown	3	11.1
Longevity of parents and siblings
	Yes	10	37.0
	No	6	22.2
	Unknown	11	40.8
Work experience
	Yes	19	70.4
	No	7	25.9
	Unknown	1	3.7
A sense of satisfaction in the current life
	Very strong	8	29.6
	Moderate	17	63.0
	A little weak	2	7.4
	Weak	0	0.0
Hobbies
	Yes	24	88.9
	No	2	7.4
	Unknown	1	3.7
Zest for life
	Yes	17
	Somewhat little	9
	A little	0
	Unknown	1

Table 3.

Social backgrounds n = 27.

Extracting thoughts about lives and descriptions such as values and persistence from collected data, the findings were analyzed qualitative and inductively. The results of the analysis are shown in Table 4. As a result, 20 codes and six subcategories were extracted in male groups. About 107 codes and 21 subcategories were extracted in female groups. Next, subcategories extracted from both male and female groups were integrated and analyzed. As a result of the analysis, six categories were extracted. The categories were “living everyday with awareness of health”: “acting aggressively”, “caring”, “accepting without resistance”, “having a positive mind,” and “spending peacefully.” The categories, “having a positive mind” and “caring” were confirmed in male groups, but they were not recognized in female ones.

Category	Subcategory	Women	Men
Living every day with health in mind	Walking and moving	0	0
	Live with caution so as not to fall	0
	To cherish that eat	0
	Use one’s head	0	0
	Act with health in mind	0
Act positively	To challenge	0	0
	Do what I want to do	0
	Engage with people	0	0
Live in peace	Live at will	0
	Live calmly and leisurely	0
	Live with gratitude	0
	Live properly	0	0
	Avoid accumulating stress	0
Have a positive feeling	Have a goal	0
	Feel happy	0
	Feel glad	0
Accept without resisting	Do not worry	0	0
	Accept the status quo	0
Be caring	Do not bother people	0
	To respect the opponent	0
	Spend without saying anything extra	0

Table 4.

Creeds about life: Comparison of men and women.

Six categories were extracted as creed about the life of the achievers, of which “having a positive mind” and “caring” confirmed in only female groups could be construed as things-related characteristics. This resembled the report [19] that there was a difference between male and female in features of the character of the centenarians. To achieve healthy longevity, things keeping in mind to live were different in men and women and at the time, it is considered that the concepts found out from this project become helpful.

7.2 Examination of frailty and fitness

The characteristics of the subjects are shown in Table 5. The subjects were 21 people (five men and 16 women). There was no obese person, and BMI was average about 21 in both men and women. The skeletal muscle mass (SMM) was 19.2 ± 2.5 kg in men and 14.8 ± 2.7 kg in women. Skeletal muscle mass index (SMI) was 6.1 ± 1.0 in men and 4.9 ± 1.2 in women. In the physical functions, grasping power was 17.9 ± 2.87 kg in men and 11.9 ± 3.7 kg in women, walking speed was 0.69 ± 0.16 m/s in men and 0.71 ± 0.24 m/s in women, and Short Physical Performance Battery(SPPB) was 6.00 ± 1.00 in men and 5.94 ± 2.38 in women. Therefore, physical depression was confirmed in many subjects.

	All (n = 21)			Men (n = 5)			Women (n = 16)
Age (y)	95.8	±	2.8	96.2	±	2.2	95.7	±	3
Height (cm)	144.6	±	7.2	151.4	±	6	142.4	±	6.3
Weight (kg)	44.9	±	9.4	50.3	±	7.7	43.2	±	9.4
BMI (kg/m^2)	21.4	±	3.7	21.9	±	2.7	21.2	±	4
SMM (kg)	15.9	±	3.2	19.2	±	2.5	14.8	±	2.7
SMI (kg/m^2)	5.2	±	1.2	6.1	±	1.0	4.9	±	1.2
Maximum circumference of lower leg (cm)	29.5	±	4.1	30.6	±	4.2	29.2	±	4.1
Grip strength (kg)	13.3	±	4.3	17.9	±	2.8	11.9	±	3.7
Gait speed (m/s)	0.71	±	0.22	0.69	±	0.16	0.71	±	0.24
SPPB	5.95	±	2.1	6.00	±	1.00	5.94	±	2.38
Frailty: Sarcopenia (Number of applicable participants)	20	:	16	5	:	4	15	:	12

Table 5.

Characteristics of the participants.

BMI, body mass index; SMI, skeletal mass index; SMM, skeletal muscle mass; SPPB, Short Physical Performance Battery.

The subjects who had frailty and sarcopenia were 20 out of 21, of which the ones who had sarcopenia were 16. In males, all five men had frailty, and four men had sarcopenia. In females, 15 out of 16 women and 12 women had sarcopenia. As a result, the number of subjects with sarcopenia was more than the ones with frailty. Although the subjects without sarcopenia had frailty, they comparatively kept their skeletal muscle mass index (SMI).

7.3 Surveys of dementia and activities of daily living: studies of ADL

The subjects were six men and 20 women, and their average age was 95.0 ± 3.0 years old. The result is shown in Table 6, and the abstract was compiled below.

1. The average score of MMSE was 21.9 ± 5.4 points (13 to 30), 11 subjects had a suspicion of being mild dementia, and another 11 had a suspicion of being dementia.

2. The average score of NM scale was 36.1 ± 10.2 points (15 to 50), 11 subjects were normal, seven were mild dementia, and eight were moderate dementia.

3. N-ADL was 41.1 ± 6.2 points (29 to 50), and 21 subjects were between mild and normal.

4. BI was 89.2 ± 10.6 points, and 21 subjects were over 85 points (level of self-support).

5. In the measurement by the cognitive functional balancer Pro, nine subjects were more than normal (between special class and second one), 10 were normal (third class), six were less than normal (fourth and fifth class), and one was aborted due to fatigue.

6. There were 14 subjects with good cognitive function (MMSE 24 points or higher). Of the 14 subjects, 11 (78.6%) had a daily routine. Specific daily routines include “going out” 3 people, “reading newspapers” 2 people, “handicraft” 2 people, “calculation” 1 person, “ four-character idiom” 1 person, “go game” 1 person, “coloring book” 1 person, “watching baseball on TV”1 person.

	Average values; (Minimum to Max)	Results (number of persons)
MMSE(score); Mini-Mental-State-Examination	21.9 ± 5.4; (13 to 30 points)	28 to 30 (Normal) 4; 24 to 27 (Mild dementia) 11; Under 23 (Possibly dementia) 11
NM scale (score)	36.4 ± 10.2; (15–50 points)	43 to 50 (Normal) 11; 31 to 42 (Mild dementia) 7; 17 to 30 (Moderate dementia) 8
N-ADL (score)	41.1 ± 6.2; (29 to 50 points)	Over 35 (Mild to Normal) 21; 17 to 30 (Moderate) 5
BI (score)	89.2 ± 10.6; (70 to 100 points)	Over 85 (Self-support) 21
Cognitive functional balancer Pro	Third class (First to fifth)	More than standard (special to second) 9; Standard (Third) 10; Less than standard (fourth and fifth) 6; *One subject aborted due to fatigue.

Table 6.

Cognitive functions, surveys of ADL n = 26.

MMSE: Mini-Mental-State-Examination; NM scale: Nishimura-type mental state scale for the elderly; N-ADL: Nishimura’s Activities of Daily Living evaluation scale for the elderly; BI: Barthel Index; Cognitive functional balancer Pro.

In this time, the result of cognitive functions varied, and it was difficult to conclude the relationship between maintenance of cognitive functions and healthy longevity. It was found that 80% of subjects with good cognitive function have a daily routine. The daily routine included contents that used the brain and hands, such as “reading newspapers,” “handicrafts,” and “calculations.” It was suggested that the presence or absence of daily routines is necessary for achieving healthy longevity.

In ADL, many subjects were between needing a light assistance and self-support. Consequently, it is suggested that maintenance of ADL is necessary to achieve healthy longevity and backed up Arai’s report [20].

8. Discussion (leaflet)

Using the survey result as evidence, leaflets compiled “four suggestions to live longer” were made to promote local care prevention activities for local community residents.

This leaflet was stated as the result of collaborative researches with Nonoichi City and Kinjo-university, and made into a familiar suggestion for local residents by putting a lot of thought. The title of the leaflet was decided as “Findings from Results of Surveys of Health and Longevity: Secrets of healthy longevity.” The ideas to live a long healthy life were suggested via four aspects such as (1) strength: (2) nutrition, (3) brain, and (4) state of mind from four aspects.

1. As for the strength, walking everyday: self-checking whether or not they felt dull and measurement of the weight were suggested. Those tell the importance of maintenance of muscle power and ADL. Although the achievers of health and longevity were physically frail, many of them kept the muscle mass comparatively and became self-support in ADL via examination of ADL and strength. Hence, motivating them to be able to do self-control was suggested. In addition, the measurement of weight was easy to do, and weight loss of the elderly led to notice their muscle weakness early. Thus, the measurement of weight was included into the suggestions because it was considered to be effective as an index to judge the subjects for themselves.

2. As for the nutrition, chewing well and eating without being fussy were suggested. Those were chosen because many achievers of healthy longevity cleaned denture and had a good appetite without having likes and dislikes from the interviews. Eating regular meals becomes the basis of a livelihood and leads to be life’s pleasure, a sense of fulfillment. However, it is necessary to create a good oral environment to have a meal firmly. It should be appreciated to value teeth, even the teeth are denture, and it is important to keep conditions of the denture available by doing maintenance regularly.

3. As for the brain, finding a daily schedule (Everything they can do every day such as reading newspapers and solving a four-character idiom). Finding the daily schedule was included into the suggestions because the subjects whose cognitive functions were good had a daily routine using their brain or hands such as reading newspapers and solving a four character idiom and calculation problems, doing handicrafts and coloring books, playing game of go, etc.

4. As for the state of mind, some words such as “I won’t worry” and “sometimes do as you like and feel at ease with positive feelings”, etc., were suggested. Those were the words many subjects told in the interview. The examples of their words were below,

“It’s easier to forget a bad thing. Just take things easy” (95 years-old woman),

“The goal is to live till 100! I want to see Tokyo Olympic” (95 years of man),

“It is important to get involved with others and enjoy it” (93 year-old woman),

“I try not to overdo it. It’s no use crying over milk. I should nature my mind” (98 years- old woman),

“I try new things” (93 years-old woman),

“I do what I want at my own pace. It’s fun to go to a place where people gather. Then, I let it all hang out. That’s the secret of longevity” (93 years man).

It was considered that many of the achievers of healthy longevity tried to keep their mind in peace and acting aggressively perhaps due to their gender or individual characters.

As stated before, there are many young people in Nonoichi City as the targeted area, and Nonoichi City has the lowest population aging rate in Ishikawa Prefecture. However, it is expected that rapid aging will advance in Nonoichi City; therefore, it is important to enlighten the local residents on healthy longevity. Thus, using the leaflet made this time, visiting lectures such as senior-oriented classes and salons for the elderly are opening. Although using the results surveyed in the world or Japan are effective, utilizing the survey results gained from predecessors who achieved health and longevity living in the same city brings a sense of affinity to the local elderly people. Besides, all suggestions this time are not difficult to do and can be adopted into the daily life. Some subjects told that they can do that, too. We want to aim to regional contribution widely and to deploy care prevention activities such as salons for the elderly on the ground of the survey results gained by collaboration between Nonoichi City and Kinjo University in the future.

As of July, 2021, survey areas are expanding to Hakusan City next to Nonoichi City, and the survey is continuing. Hakusan City consists of a vast area from the coast to the foot of Mt. Hakusan and has a higher aging rate than Nonoichi City and different features from Nonoichi City. We consider to continue the survey and find the relationship between regional characteristics and health and longevity.

8.1 Limitations of this project

The possibility that there was bias of the subject cannot be denied because the subjects were few; this survey was not complete enumeration for every old people over 90 living in Nonoichi City, choices of the subject were not randomized, but were introduced by care managers (snowball sampling).

However, it is considered that the surveys of the achievers of healthy longevity who could take “interviews” and “investigations of strength” at the survey were generally conducted.

9. Conclusions

To maintain health, find frailty early, and prolong healthy life expectancy, secrets of health and longevity were explored with aiming at the elderly over 90 in collaboration among Kinjo University and Nonoichi City. Utilizing the secrets of longevity of the achievers to care prevention activities is expected to help as health promotion closely related to the residents in the same area.

Acknowledgments

For doing this project, we are really grateful to the local residents living in Nonoichi City and every one in Health and Longevity divisions for cooperating.

Conflict of interest

The authors have no conflicts of interests.