(2023) 23:397
Kouzuki et al. BMC Geriatrics
https://doi.org/10.1186/s12877-023-04119-2

BMC Geriatrics

RESEARCH

Open Access

Suggestions on the ideal methodof conducting community screenings for older
adultsMinoru Kouzuki1*, Nobuto Tanaka2, Madoka Miyamoto2 and Katsuya Urakami2

Abstract
Background/Objectives Since dementia and frailty lead to a reduced quality of life and risk of needing long-termcare in the older adults, we hypothesized that evaluations related to dementia and frailty would be useful and of highinterest in screening for the older adults. Therefore, we conducted a community screening incorporating multiple
simple evaluations related to dementia and frailty. In addition to various functional evaluations, we investigatedinterest in tests, thoughts on the disease, and the relationships between subjective (i.e., how one feels about oneself )and objective evaluations (i.e., the results of tests and rating scales). The purpose of this study was to examine thethoughts regarding tests and diseases and the functions that make it difficult to accurately perceive changes by oneself, and to obtain suggestions on the ideal method of community screening for the older adults.
Subjects/Methods The participants were 86 people aged 65 and over living in Kotoura Town who participatedin the community screening, for which we obtained background information and body measurements. We also
assessed physical, cognitive and olfactory function, evaluated nutritional status, and we administered a questionnaire(interest in tests, thoughts on dementia and frailty, and a subjective functional evaluation).
Results Regarding interest in tests, the participants answers were highest for physical, cognitive and olfactory function, in that order (68.6%, 60.5%, and 50.0%, respectively). In the survey on thoughts on dementia and frailty, 47.6%
of participants felt that people with dementia were viewed with prejudice, and 47.7% did not know about frailty.
Regarding the relationship between subjective and objective evaluations, only the assessment of cognitive function
did not show a correlation between both evaluations.
Conclusions From the viewpoint of the participants’ degree of interest in and the need for accurate evaluations
through objective examination, the findings suggest that the assessment of physical and cognitive function may bebeneficial as a screening tool for older adults. Objective evaluation is essential, particularly for assessing cognitive
function. However, approximately half the participants believed people with dementia were viewed with prejudice
and did not know about frailty, which may lead to barriers to testing and low interest. The importance of increasing
the participation rate in community screening through disease-related educational activities was suggested.
Keywords Dementia, Frailty, Screening, Cognitive function, Physical function, Olfactory function, Nutritional status*Correspondence:
Minoru Kouzuki
kouzuki@tottori-u.ac.jp
Full list of author information is available at the end of the article© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
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Kouzuki et al. BMC Geriatrics(2023) 23:397

Introduction
The number of older people with dementia is estimatedto increase [1] and has become a major public healthproblem. However, some people with mild cognitive
impairment (MCI), a pre-dementia stage, revert to normal cognition [2]. In addition, a 2-year lifestyle-related
multidomain intervention in a large randomized controlled trial improved cognitive function in older adults
who were from the general population and were at anelevated risk of developing dementia [3]. It may be possible to prevent dementia by detecting it at the pre-diseasestage and implementing interventions. Appropriate testing is necessary for early detection, and for this reason,
it is important to establish a system that enables people
to undergo check-ups in their local area and examinations at nearby medical institutions [4, 5]. However, in astudy that conducted a questionnaire survey of the older
adults, more than half of the respondents were unwillingor undecided about undergoing regular dementia screening [6]. A previous study reported that awareness of theseriousness and knowledge of a preventive lifestyle had asignificant influence on the intention to undergo screening [7]. Thus, individual awareness and interest are vital
factors. In addition, the stigma associated with dementia is a concern [8], and there may be resistance to participation in screening that tests cognitive function only.
Various risk factors for cognitive decline and symptoms
to precede cognitive decline have been suggested [9–11].
By adding evaluations other than cognitive function,
it is expected that the content will attract the attentionof many people, reduce resistance to participation, andlead to risk management of cognitive function decline.
In recent years, in addition to dementia, frailty has beendrawing attention in Japan, leading to a reduction in thequality of life and the risk of needing long-term careamong the older adults. As frailty can increase the riskof dementia incidence, disability incidence, and mortality [12–17], we hypothesized that evaluations related todementia and frailty would be useful and of high interestin screening for the older adults.
Therefore, we conducted a community screening incorporating multiple simple evaluations related to dementia
and frailty, and in addition to various functional evaluations, we investigated interest in tests as well as prejudiceagainst and awareness of prevention against dementia
and frailty. Additionally, we explored the relationshipbetween subjective and objective functional decline foreach test item. By examining the presence or absenceof divergence between subjective and objective evaluations, we scrutinized the necessity of objective functional
evaluation by identifying items that make it difficult toaccurately perceive changes. By analyzing the results,
we aimed to obtain suggestions for the ideal method ofPage 2 of 12

community screening for the older adults, which canbe carried out even in local areas where there are no
specialists.

Methods
ParticipantsThis study included 86 people who participated in a community screening conducted in Kotoura Town (Tottori
Prefecture, Japan) from July to November of 2021. Inclusion criteria were those who lived in Kotoura Town andwere over 65 years old. Exclusion criteria were those
restricted from strenuous activities by their physicians
owing to pre-existing medical conditions. Information
about the community screening was provided on posters
put up in Kotoura Town or by distributing them to residents with the cooperation of Kotoura Town Hall staff.
We conducted the present study with the approval of
the Ethics Committee of the Tottori University Faculty of
Medicine (No. 20A227). Prior to conducting the research,
the participants were informed about the study’s aims
and their consent was obtained in writing.
Community screening measurement items
Participant demographic characteristics

Age, sex, years of education, number of drugs taken,
and medical history (hypertension, dyslipidemia, diabetes mellitus, olfactory disorder with obvious cause, andlocomotive organ disorder) were investigated throughinterviews.
Body measurements

Height was measured using a tape measure attached to
the wall and weight, body fat percentage, basal metabolic rate, body water percentage, and muscle mass were
measured using a weight and body composition monitor with dual frequency bioelectrical impedance analysis(RD-800; TANITA Corporation, Tokyo, Japan). From theresults, we computed body mass index ((BMI) = weight(kg) / ­height2 ­(m2)) and appendicular skeletal muscle
mass index ((SMI) = arm and leg skeletal muscle mass(kg) / ­height2 ­(m2)).
Assessment of cognitive function

To assess cognitive function, we used an existing computerized test battery for Alzheimer’s disease screening (developed by Nihon Kohden Corporation, Tokyo,
Japan, with the product name “monowasure soudan
proguramu (MSP)” (which means forgetfulness consultation program)) [18]. In the test, the participants performed on their own, following the instructions givenby the computer (MSP-1100; Nihon Kohden Corporation, Tokyo, Japan). It comprises four evaluation items:
a three-word memory test, a temporal orientation test,

Kouzuki et al. BMC Geriatrics(2023) 23:397

a 3D visual-spatial perception test, and a delayed recall
test. The maximum score was 15 points for answering allquestions correctly and the minimum score was 0 points
for answering all questions incorrectly. The sensitivity
and specificity for distinguishing between healthy controls and Alzheimer’s disease were 96% and 86%, respectively, and the cutoff value was set to 12/13 points [18].
Assessment of olfactory function

Olfactory function may be impaired prior to cognitive
decline [10], hence it may be useful for the early detection of dementia. Olfactory function was assessed using
the Open Essence (OE) test (FUJIFILM Wako Pure
Chemical Corporation, Osaka, Japan) [19–21]. The OE
test included 12 odor items. Each odorant was containedin 12 cards and folded in two. In the center of the left halfof the open card, microencapsulated test odorants wereapplied instead of glue. On the other side, six alternatives(four alternatives for odor name, as well as “detectable but
not recognizable” and “no smell detected”) were printed.
Participants opened the odor cards one by one in order,
sniffed them, and identified the odorant among 6 choices.
A score of 1 point per odor and a score of 12 points indicated that the participant had answered all questions
correctly, and a score of 0 indicated that the participant’s
answers were all incorrect. It has been shown that setting a cut-off value of the OE test of 7 points or less asa screening criterion for olfactory disorders is useful fordifferentiation [21].
Assessment of physical function

Physical function tests included evaluation of grip
strength, balance, gait speed, the chair sit-stand test, andthe Timed Up and Go test (TUG) [22]. We also calculated
the short physical performance battery (SPPB) score [23]based on the results of the balance, gait speed, and chairsit-stand tests. On the SPPB, the participant can gain amaximum of 12 points (0 to 4 points for each of the three
items), and a higher score denotes better physical performance. An SPPB score of ≤ 9 points is considered usefulfor predicting mortality [24], and in this study, individuals with a score of ≤ 9 points were judged to have low
SPPB scores.
Grip strength was evaluated using a hand dynamometer (T.K.K.5401; Takei Scientific Instruments Co. Ltd.,
Niigata, Japan). Measurements were taken once on eachside in a standing position; we used the results from thestrongest hand in the present analysis.
We assessed balance strength for the time required tokeep standing in the side-by-side, semi-tandem, and fulltandem positions. The maximum measurement timewas 10 s in each standing position, and the full tandem

Page 3 of 12

position was performed only when the participant could
hold both the side-by-side and semi-tandem positions for
10 s.
Gait speed was assessed by measuring the walking timeat 4 m and calculating the gait speed for 1 s. To reproduce a situation close to normal walking, the participant
was asked to walk 6 m with an additional 1 m each before
and after the 4 m measurement point.
In the chair sit-stand test, participants were asked to sit
down on a chair, fold their arms in front of their chest,
and repeat five consecutive sit-to-stand motions from asitting position as quickly as possible. The time required
to complete the fifth standing movement from the startof the movement was measured.
The TUG test began from sitting with the back against
the back of the chair, standing up from the chair, walking
to a landmark 3 m ahead, turning around, and measuring
the time it took to sit back in the chair. The results of the
maximum walking speed were used in the analysis.
Assessment of frailty

We assessed physical frailty using the Japanese versionof the Cardiovascular Health Study criteria [25]. These
criteria comprise five domains: shrinking, low activity,
exhaustion, weakness, and slowness. (i) Shrinking: Have
you lost 2 kg or more in the past 6 months? (“Yes” is one
point); (ii) low activity: (a) Do you engage in moderatelevels of physical exercise or sports aimed at health? (b)Do you engage in low levels of physical exercise aimed at
improving health? (“No” to both questions is one point);(iii) exhaustion: In the past 2 weeks, have you felt tired
without a reason? (“Yes” is one point); (iv) weakness: grip
strength < 28 kg in men or < 18 kg in women (one point if
there is a decrease); and (v) slowness: gait speed < 1.0 m/s(one point if there is a decrease). Participants with noneof these components were considered robust, those with
one or two components were considered to be pre-frailty,
and those with three or more components were considered frailty [25].
Assessment of sarcopenia and dynapenia

We diagnosed sarcopenia and dynapenia based on the
Asian Working Group for Sarcopenia 2019 criteria and
Yamada et al. [26, 27]. Muscle functional decline wasdefined as a grip strength of < 28 kg in men or < 18 kg in
women and/or gait speed of < 1.0 m/s, and reduced muscle mass was defined as an SMI of < 7.0 kg/m2 in menor < 5.7 kg/m2 in women.
Sarcopenia was defined as low muscle mass and low
muscle function; pre-sarcopenia was defined as low muscle mass without low muscle function; dynapenia wasKouzuki et al. BMC Geriatrics(2023) 23:397

defined as low muscle function without low muscle mass;and normal was defined as anything other than the above.
Nutritional related assessment

Nutritional assessment included evaluation of dietaryvariety using the dietary variety score (DVS) developedby Kumagai et al. [28] and the Mini Nutritional Assessment-Short Form (MNA®-SF) [29, 30].
The DVS is an assessment that investigates the weekly
frequency of intake of 10 food-based components,
including fish and shellfish, meat, eggs, milk, soybean
products, green and yellow vegetables, seaweed, potatoes, fruits, fat, and oil. The total DVS ranges from 0 to
10 points, with the intake of each food group assigned 1
point for a response of “eat almost every day” and 0 for“eat once every two days,” “eat once or twice a week,” or“eat hardly ever.” A previous study evaluated DVS among
608 community-dwelling residents and found that the­10th percentile of DVS scores for all subjects was ≤ 3
points [28]. Hence, in this study, a score of 3 or less wasconsidered to indicate low diversity in food intake.
The MNA®-SF consists of six items: reduction in foodintake over the past three months, weight loss during thepast three months, mobility, psychological stress or acutedisease in the past three months, neuropsychologicalproblems, and BMI. The score ranges from 0 to 14 andis interpreted as follows: 12–14 indicates normal nutritional status, 8–11 denotes a risk of malnutrition, and
0–7 means malnourished [30].
Questionnaire

We conducted a questionnaire on interest in the test, thesubjective state assessment, and dementia- and frailtyrelated items.
For the tests of interest, participants were asked,"please check the evaluation that you are interested in theitems of this community screening," and selected fromfive items: body measurements (e.g., height and weightmeasurements), the cognitive function test, the olfactory
function test, and the physical function test (e.g., grip
strength, lower limb muscle strength, balance strength,
body composition measurement), and evaluation ofnutritional status. The questionnaire allowed for multiple
responses.
As a subjective condition questionnaire, we investigated the perception of functional decline in six areas:decline in cognitive function, decline in olfactory function, decline of upper extremity muscles, decline of leg
muscles, decline in physical function, and decline in
nutritional status. Participants were asked to respondto a question about each decline in function using four
options: “strongly disagree”, “disagree,” “agree,” andPage 4 of 12“strongly agree.” We instructed them to answer “disagree”
if they felt that it was appropriate for their age.
We investigated the degree of social prejudice andinterest in prevention by using questions on dementia
and frailty. Regarding dementia-related questions, we
asked whether people with the disease were viewed withprejudice, along with their thoughts about prevention(motivation for preventive activities at home, willingness
to participate in preventive care projects held by municipalities, the presence/absence of current preventive
activities, and thoughts on the effectiveness of preventive
efforts). With regard to frailty, in addition to the above
questions, we asked about understanding the definition.
If they answered “I don’t know” to the question about
the definition of frailty, they were asked not to answer
questions about prejudice against and the prevention offrailty.
Statistical analysis

We performed statistical analysis using the software
SPSS version 27 (IBM Corporation, Tokyo, Japan). We
used the Shapiro–Wilk test to assess the normality of thedata, and Levene’s test to assess the equality of variance.
We employed univariate and multivariate binary logistic regression analyses to establish associations between
whether participants felt that people with dementia andfrailty were viewed with prejudice (the dependent variable) and background factors (e.g., age, sex, years of education, and number of drugs as independent variables).
We classified those who answered “agree” or “somewhat
agree” to questions about whether people with dementia and frailty are perceived with prejudice as the groupthat felt social prejudice. In addition, we used one of thefour items (age, gender, years of education, and numberof drugs) as the target factor to investigate the effect,
and we adjusted the remaining three items as covariates. However, 14 people answered that they agreed with
the question “Do you think people with frailty tend tobe viewed with prejudice?” As the validity of the logistic
model becomes problematic when the ratio of the number of events per variable analyzed is small [31], we did
not perform a covariate-adjusted statistical analysis of
the association between background factors and prejudice against frailty. In the logistic regression analysis, we
calculated the unadjusted and adjusted odds ratios (OR)and 95% confidence intervals (CIs). Regarding the link
between the subjective and objective functional evaluations, we divided responses regarding subjective function
into “strongly agree:4 points,” “agree:3 points,” “disagree:2
points,” and “strongly disagree:1 point.” We used tests
or existing questionnaires with established usefulness,such as the DVS and MNA®-SF, for objective evaluation. In other words, in this study, we defined subjective

Kouzuki et al. BMC Geriatrics(2023) 23:397

evaluation as how participants feel about themselves
and objective evaluation as the results of tests and rating
scales. We determined the association between the subjective and objective functional evaluations by calculating Spearman’s rank correlation coefficient. In addition,
we made comparisons of various test outcomes between
groups with high and low scores on cognitive function
tests using Student’s t-test, Welch’s t-test, or the Mann–
Whitney U test.
All statistical significance tests were two-sided, and analpha level of 0.05 was statistically significant.

Results
Characteristics of the participants

Table 1 presents the characteristics of the participants.
The mean age was 77.3 (standard deviation: 6.7) years,
87.2% were female; and the mean years of education was
11.3 (standard deviation: 1.8) years. The prevalence ofcognitive decline was 12.8%. The rate of pre-frailty andfrailty were 35.5% and 3.9%, respectively. Regarding otherresults, notable characteristic was that 70.7% of participants were judged to have olfactory disorder, which isa high percentage. Table 2 shows the results of the subjective functional assessments. A fairly large numberof participants—more than 60%—responded that they
“strongly agree” or “agree” with experiencing a decline
in cognitive function, a decline of the upper extremity
muscles, a decline of leg muscle, and a decline in physicalfunction (61.6%, 75.6%, 62.8%, and 72.1%, respectively).
Tests of interest

Figure 1 presents the results of the questionnaire on tests
of interest. Items of interest were, from the highest percentage, the physical function test (68.6%), the cognitive
function test (60.5%), the olfactory function test (50.0%),
nutritional status (39.5%), and body measurements(36.0%). In addition, 82.6% of the participants answeredthat they were interested in either the physical or cognitive function test, with a rate of 90.7% when the olfactory
function test was added to the above two items, 84.9%
when nutritional status was added to the above twoitems, and 88.4% when the aspect of body measurements
was added to the above two items.
Questionnaire results regarding prejudice against,
and prevention of, dementia and frailty

Table 3 depicts the outcomes regarding prejudiceagainst, and prevention of, dementia and frailty. The
results of prejudice against, and prevention of, frailty
were responses from 45 people, excluding 41 (47.7%)
who did not know about frailty. Participants answered“agree” or “somewhat agree” to questions about whether

Page 5 of 12

people with dementia and frailty are viewed with prejudice (47.6% [41 out of 86] for dementia and 31.1% [14out of 45] for frailty). We performed logistic regression
analyses to examine the factors related to the degree ofsocial prejudice against dementia or frailty (Table 4).
Age (OR = 0.90, 95% CI = 0.82–0.99, p = 0.030) and yearsof education (OR = 1.46, 95% CI = 1.03–2.06, p = 0.034)
were significantly associated with the feeling that people
with dementia are viewed with prejudice in the adjusted
model. In other words, younger people or those withmore years of education were more likely to feel thatpeople with dementia were viewed with prejudice. As forthe prevention of dementia and frailty, many participants
wanted to work on a simple preventive method that could
be performed at home: with 79.1% for dementia prevention and 82.2% for frailty prevention. However, very few
participants thought that efforts to prevent dementia andfrailty would be effective, with 11.6% for dementia prevention and 2.2% for frailty prevention.
The correlation between the subjective and objective
evaluations

Table 5 portrays the outcomes of the correlation analysis between the subjective and objective evaluation
items that are considered to be related. Except for cognitive function, the results of one or another objective
assessment revealed a significant correlation with thesubjective assessment. Concerning cognitive function,
the results indicated that even participants with highscores on the cognitive function test often complained of
declining cognitive function (Additional File 1: Table S1).
In addition, participants with lower scores on cognitive
function tests performed significantly worse on the balance test (semi-tandem stand), gait speed, SPPB, andTUG tests than those with higher scores (Additional
file 1: Table S2).

Discussion
Among community residents aged 65 and over who participated in the community screening, the percentage of
respondents who expressed interest in physical or cognitive function tests were more than 60%, and more than
80% were interested in either physical or cognitive function tests. These results indicate a high level of interestin cognitive and/or physical function tests. Moreover,
12.8% of the participants had cognitive decline, 3.9%
were frailty, and 35.5% were pre-frailty. Several crosssectional studies in Japan conducted on communitydwelling with individuals over 65 years old [32–37] wasreported that the rate of cognitive impairment was 2.0–
10.8% in the urban areas and 8.4–21.8% in the rural areas,
and the rates of frailty and pre-frailty were 8.7–12.8% and35.4–47.7%, respectively. There are some differences inKouzuki et al. BMC Geriatrics(2023) 23:397

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Table 1 Characteristics of the participants

Table 1 (continued)
All participants (n = 86)

Age (years)

77.3 ± 6.7

MNA®-SF (points)

GenderAll participants (n = 86)
12.4 ± 1.4

Normal nutritional status

68 (79.1)

Male

11 (12.8)

At risk of malnutrition

18 (20.9)

Female75 (87.2)

Malnourished

0 (0)Education (years)

11.3 ± 1.8

Number of drugs

2.2 ± 2.0

DVS (points)

Medical history

60 (69.8)

Low score (DVS≦3)

26 (30.2)

Hypertension

41 (47.7)

Dyslipidemia

32 (37.2)

Diabetes mellitus

10 (11.6)b

Sample size is 76 (9 men / 67 women)

Olfactory disorder

3 (3.5)c

Sample size is 75

Locomotive organ disorder21 (24.4)dSample size is 77

BMI (kg/m )22.5 ± 3.1

eSample size is 73

MSP (points)

13.9 ± 1.6

fSample size is 75 (9 men / 66 women)2Non-cognitive decline (MSP≧13)

75 (87.2)

Cognitive decline (MSP≦12)11 (12.8)

OE (points)a

5.8 ± 2.7

Non-olfactory disorder (OE≧8)24 (29.3)

Olfactory disorder (OE≦7)

58 (70.7)

Grip strength (kg)bMale

34.6 ± 6.2

Female21.4 ± 4.1

Balance test (sec)c
Side-by-side stand10.0 ± 0

Semi-tandem stand10.0 ± 0.4

Full tandem stand9.5 ± 1.5

Gait speed (m/sec)d1.2 ± 0.3

Chair sit-stand test (sec)e

9.8 ± 4.7

SPPB (points)e11.4 ± 1.1

High score (SPPB≧10)68 (93.2)

Low score (SPPB≦9)5 (6.8)TUG (sec)e

7.1 ± 2.0

SMI (kg/m2)fMale

7.5 ± 0.8

Female6.5 ± 0.8

Body fat percentage (%)

29.2 ± 7.8

Basal metabolic rate (kcal)

1022.3 ± 191.7

Body water percentage (%)

49.4 ± 5.4

Frailty ­statusg
Robust46 (60.5)

Pre-frailty

27 (35.5)

Frailty

3 (3.9)Sarcopenia and dynapenia s­ tagingh
Normal52 (70.3)

Dynapenia

14 (18.9)

Presarcopenia

1 (1.4)

Sarcopenia

7 (9.5)5.0 ± 2.5

Not low score (DVS≧4)

Data presented as mean ± standard deviation or number (%)
aSample size is 82g

Sample size is 76hSample size is 74

BMI Body mass index, MSP a computerized test battery for Alzheimer’s disease
screening (produced by Nihon Kohden Corporation, called monowasure soudan
proguramu (forgetfulness consultation program)), OE Open essence, SPPB Shortphysical performance battery, TUG​Timed Up and Go Test, SMI Skeletal muscle
mass index, MNA®-SF Mini Nutritional Assessment-Short Form, DVS Dietaryvariety scoreresults due to regional differences, differences in sociodemographic characteristics, and differences in evaluation methods. However, potentially there are people
with physical and cognitive decline in the community.
The importance of objective evaluations can be evident
in the fact that more than 60% of participants felt subjectively impaired in their physical and cognitive functions.
Furthermore, by conducting other tests in addition to thephysical and cognitive function tests, the rate of interestin the test will increase, which is expected to improve theparticipant rate; it is also meaningful in terms of knowing the risk of various diseases. In particular, adding anolfactory test could attract more than 90% of participants. Since olfactory function may be impaired prior tocognitive decline [10], it is highly valuable to introduce it
into community screenings. However, in this study, thepercentage below the cut-off value in the olfactory test
was very high at 70.7% in this study. Olfactory function
declines with age [38, 39], and a previous study that conducted OE in community-dwelling older adults with amean age of 73 years also demonstrated a high proportion (67.4%) with impaired olfactory function [37]. Thus,
it is necessary to understand the high detection rate ofdecreased olfactory function when conducting olfactory tests in community screenings for the older adults.
In addition, since olfactory impairment may precedea decline in cognitive function [10], we believe that it isimportant to conduct a longitudinal evaluation of people

Kouzuki et al. BMC Geriatrics(2023) 23:397

Page 7 of 12

Table 2 Results of subjective functional assessment
Number (%)
Decline in cognitive function
Strongly disagree

5 (5.8)Disagree28 (32.6)

Agree

45 (52.3)

Strongly agree

8 (9.3)Decline in olfactory function
Strongly disagree

23 (26.7)

Disagree36 (41.9)Agree

19 (22.1)

Strongly agree

8 (9.3)Decline of upper extremity muscles
Strongly disagree

3 (3.5)

Disagree18 (20.9)

Agree

49 (57.0)

Strongly agree

16 (18.6)

Decline of leg muscle
Strongly disagree

6 (7.0)

Disagree26 (30.2)

Agree

37 (43.0)

Strongly agree

17 (19.8)

Decline in physical function
Strongly disagree

3 (3.5)

Disagree21 (24.4)

Agree

49 (57.0)

Strongly agree

13 (15.1)

Decline in nutritional status
Strongly disagree

20 (23.3)

Disagree46 (53.5)

Agree

18 (20.9)

Strongly agree

2 (2.3)Fig. 1 Questionnaire results about tests of interest

with reduced olfactory function but without reduced
cognitive function.
Except for cognitive function, the results of one ormore objective assessments revealed a significant correlation with the subjective assessment; as such, evena simple questionnaire survey can capture the state tosome extent. Therefore, we believe that this can be simplified for the evaluation of physical functions that areof great interest. However, we assessed multiple items
for physical function, and if it was difficult to spend timeand effort, we believe it is acceptable to conduct a questionnaire survey and additionally select simple objective
evaluation items such as grip strength and walking speed,which are related to the judgment of physical frailty [25],or items that showed significant deterioration in cognitively impaired participants (Additional file 1–Table S2).
However, regarding cognitive function, the results indicated that even participants with high scores on the
cognitive function test often complained of declining
cognitive function. Nogi et al. also reported that older
adults with or without cognitive dysfunction were excessively aware of memory loss [40]. Regarding cognitive
function, the objective evaluation is necessary, regardlessof the presence or absence of subjective symptoms.
From a survey of thoughts about dementia, we foundthat approximately half the participants felt that people with dementia were viewed with prejudice. There isa possibility that some participants felt that people withdementia tended to be viewed with prejudice from public
impressions, even if they themselves did not have prejudice against people with dementia. Therefore, this finding
should be interpreted with caution. However, the results
can be interpreted as reflecting the social climate of prejudice against dementia, as they indicate that participantsKouzuki et al. BMC Geriatrics(2023) 23:397

Page 8 of 12

Table 3 Questionnaire results regarding prejudice against, and prevention of, dementia and frailty
Number (%)
Do you think people with dementia tend to be viewed with prejudice?
Agree

10 (11.6)

Somewhat agree

31 (36.0)

Somewhat disagree

17 (19.8)

Disagree28 (32.6)

What are your thoughts on the prevention of dementia? (multiple answers allowed)
If there is a simple preventive method that can be done at home, I would like to work on it

68 (79.1)

I would like to participate in preventive care projects held by municipalities

42 (48.8)

I am already doing some kind of preventive activity

33 (38.4)

I do not think we can expect much of an effect from dementia prevention efforts

10 (11.6)

Do you know what the term fureiru (frailty in English) refers to?
Healthy condition

2 (2.3)

State of weakness

33 (38.4)

State of need for long-term care

10 (11.6)

I do not know

41 (47.7)

Do you think people with frailty tend to be viewed with prejudice?aAgree

1 (2.2)

Somewhat agree

13 (28.9)

Somewhat disagree

17 (37.8)

Disagree14 (31.1)

What are your thoughts on the prevention of frailty? (multiple answers allowed)aa

If there is a simple preventive method that can be done at home, I would like to work on it

37 (82.2)

I would like to participate in preventive care projects held by municipalities

24 (53.3)

I am already doing some kind of preventive activity

22 (48.9)

I do not think we can expect much of an effect from frailty prevention efforts

1 (2.2)

The results of responses from 45 people, excluding those who answered “I don’t know” to the question about the definition of frailty are shown

had prejudice-related experiences directly or indirectly.
The results showed that social prejudice against people
with dementia remains highly prevalent among Japanese people. In addition, younger age or more years ofeducation was associated with the feeling that people
with dementia are viewed with prejudice. This is similar to a previous study showing that respondents aged
75 years or older expressed less perceived stigma than
younger respondents [41]. There may be various factorsthat explain this, but we think that younger people tend
to have prejudices because they have few opportunities tointeract with people with dementia and feel it is someone else’s problem. Moreover, people may tend to accept
being diagnosed with dementia as they age. In contrast,
a study conducted in 2008 on older Korean Americans
indicated that feelings of shame associated with family
members having Alzheimer’s disease are more likely tobe reported by individuals with lower levels of educationand less knowledge of Alzheimer’s disease [42]. Although
the countries, years, and methods surveyed were different, the results differed. Previous investigations have suggested that a higher level of education may be associatedwith more knowledge of dementia [42, 43]. However,based on our results, we speculate that people with a highlevel of education may have acquired a certain amount ofknowledge, but at the same time, they may have acquired
more incorrect information, making them more likely
to have prejudice. As health professionals expressed thehighest levels of stigma compared to other groups (social
workers, students, retired people, and the public) [41], it
is possible that a high level of knowledge does not simply mean less prejudice. Furthermore, we asked whether
people with dementia tend to be viewed with prejudice.
Thus, it is also conceivable that more knowledgeable people may have a higher awareness of current social climate— such as the stigma associated with dementia, which
is a concern [8]. However, we have not been able to findany past research results that support our view; therefore,
we should be careful in interpreting this because of ourunsubstantiated opinion. In the future, we think it is necessary to examine whether there are cultural differences
and historical backgrounds in prejudice against dementia. In addition, there is a need to accurately identify
the factors associated with prejudice by examining theKouzuki et al. BMC Geriatrics(2023) 23:397

Page 9 of 12

Table 4 Analysis of factors influencing whether participants feel social prejudice against people with dementia or frailty
Adjustedb

Unadjusted
OR (95% CI)

P value

OR (95% CI)

P value

Association with prejudice against dementia
Age

0.86 (0.79—0.94)

0.001

0.90 (0.82—0.99)

0.030

Gender (Female)

0.73 (0.21—2.60)

0.626

0.96 (0.23—4.07)

0.952

Education

1.74 (1.27—2.38)

0.001

1.46 (1.03—2.06)

0.034

Number of drugs

0.86 (0.69—1.08)

0.196

1.01 (0.78—1.30)

0.959

Age

1.00 (0.89—1.13)

0.976

-c

Gender (Female)

0.54 (0.10—2.84)

0.469

-c

Education

1.12 (0.78—1.60)

0.549

-c

Number of drugs

1.34 (0.92—1.97)

0.133

-c

Association with prejudice against ­frailtyaa

The results of responses from 45 people, excluding those who answered “I don’t know” to the question about the definition of frailty are shownb

Analysis was performed using one of the four items (age, gender, education, and number of drugs) as the independent variable and the remaining three asadjustment covariatescFourteen people agreed with the question, “Do you think people with frailty tend to be viewed with prejudice?” Because the validity of the logistic model becomesproblematic when the ratio of the number of events per variable analyzed is small, statistical analysis was not performed

OR, odds ratio; CI, confidence interval

Table 5 Correlation between subjective and objective evaluations
Subjective evaluation based on the questionnaire
Test item

Samplesize

If fluctuations match

Cognitivefunction-0.053

MSP

86

Negative correlation

OE

82

Negative correlation

Olfactory
function

Upper extremity
musclesLegmuscles

Physicalfunction

Nutritional
status-0.227 *Grip strength
Male

9Negative correlation-0.798 *-0.329Female67

Negative correlation-0.130-0.06875

Negative correlation

Balance test
Side-by-side stand-a-a

Semi-tandem stand75

Negative correlation-0.058-0.042

Full tandem stand75

Negative correlation-0.205

0.018

Gait speed

77

Negative correlation-0.336 *-0.241 *Chair sit-stand test

73

Positive correlation

0.233 *

0.193

SPPB

73

Negative correlation-0.291 *-0.064

TUG​

73

Positive correlation

0.454 *

0.325 *

SMI
Male

9

Negative correlation

0.222

0.062

0.299

Female66

Negative correlation-0.033

0.094

0.036

MNA®-SF

86

Negative correlation

86

Negative correlation-0.236 *DVS

86Negative correlation-0.143BMI-0.226 *The data are presented as correlation coefficients. All correlation analyses were conducted using Spearman’s correlation coefficients
Only correlation results with objective evaluations considered relevant to each subjective evaluation are shownaStatistical analysis was not possible because the results for side-by-side standing times were the same for all participants*

p < 0.05

MSP a computerized test battery for Alzheimer’s disease screening (produced by Nihon Kohden Corporation, called monowasure soudan proguramu (forgetfulness
consultation program)), OE Open essence, SPPB Short physical performance battery, TUG​Timed Up and Go Test, SMI Skeletal muscle mass index, BMI Body mass index,
MNA®-SF Mini Nutritional Assessment-Short Form, DVS Dietary variety score

Kouzuki et al. BMC Geriatrics(2023) 23:397

presence or absence of additional factors, such as modifiable acquired variables associated with prejudice, andusing reliable methods to assess the presence of prejudice. Prejudice regarding the disease can be a barrier totesting. However, appropriate interventions can enhance
the public’s knowledge of dementia and reduce dementia-related stigma, especially for those with higher levelsof stigma [44]. We think it is necessary to provide correct
information, even to young people, and to encourage achange in awareness so that prejudice can be eliminated.
Regarding frailty, in a previous study that surveyed acommunity-dwelling older population in Japan in 2018,
awareness of the term frailty was estimated at 20.1% [45].
In contrast, in this study, 38.4% of the participants correctly understood the definition. Degree of recognition
seems to be increasing little by little, but 13.9% of theparticipants misunderstood, and 47.7% of the participants answered that they did not know. From the above,
we believe that the term is not yet well-known amongolder adults. We assert that increasing the degree of recognition of frailty by disseminating correct information
will heighten interest in testing.
In addition, many people believe that dementia andfrailty can be prevented, and many people would like towork on doing so if there is a simple preventive methodthat can be performed at home. Farming, exercise, intellectual activity, and social participation help improveand prevent frailty [46], and certain active lifestyles may
contribute to the return of cognitive function to normal
levels after MCI [47]. In other words, many actions canbe taken in daily life to prevent dementia and frailty. We
affirm that it is important to establish a system that provides tests as well as post-test measures.
This study has several limitations. First, the participants
were those who voluntarily participated in a community
screening for the older adults conducted in Kotoura Town.
A previous study reported that non-participation in a physical checkup may be related to poor health awareness [48].
Therefore, it is possible that there was a sampling bias inthat many of the participants were highly health conscious.
Second, nearly 90% of the participants were female. As
such, our data might reflect the results for women in particular. Third, information on sociodemographic characteristics was scarce. Therefore, it was not possible to interpretthe results by considering the characteristics of the participants such as their occupation, marital status, lifestyle,and income. Additionally, the lack of detailed participantcharacteristics may make comparisons with other studies
difficult. The fourth limitation is the small sample size. In
addition, there were missing values for many evaluation
items; therefore, the number of subjects for the analysis waseven smaller. We believe that an examination with a larger
sample size is required to draw more accurate conclusions.

Page 10 of 12

Conclusions
Because there are a certain number of people in the community who have cognitive decline and frailty or a prodromal state (pre-frailty), it is important to conduct community
screenings and evaluate them. Regarding the content ofcommunity screening for the older adults, from the viewpoint of the participants’ degree of interest and the needfor accurate objective evaluation, the evaluation of physical and cognitive functions may be beneficial. Cognitive
function cannot be accurately judged by oneself; therefore,
an objective examination is essential. However, regarding
physical function, we found a relationship between subjective symptoms and test results. If it is difficult to spend thetime and effort, we believe this can be simplified. Furthermore, by conducting other tests in addition to physical andcognitive function tests, the rate of interest in testing will
increase, which is expected to make community screening
attractive to many people. The results of this study will be
helpful as objective information for selecting test items forcommunity screening of older individuals. However, there
is a concern that approximately half of the participants
felt that people with dementia were viewed with prejudice
and did not know about frailty, which may lead to barriers
regarding testing and low interest. The results of this study
indicate that community screening for the older adults to
conduct evaluations related to dementia and frailty is useful and of high interest, but also suggest the importance ofincreasing the participation rate in community screening
through disease-related educational activities.
Abbreviation
BMI	Body mass index
MSP	A computerized test battery for Alzheimer’s disease screening(produced by Nihon Kohden Corporation, and product name ismonowasure soudan proguramu (MSP) (it means forgetfulness
consultation program))
OE	Open essence
SPPB	Short Physical Performance Battery
TUG​	Timed Up and Go test
SMI	Skeletal muscle mass index
MNA®-SF	Mini Nutritional Assessment-Short Form
DVS	Dietary variety score
OR	Odds ratio
CI	Confidence interval
MCI	Mild cognitive impairment

Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12877-​023-​04119-2.
Additional file 1.
Acknowledgements
We thank the people who participated in this study. We also thank the staffof the Community General Support Center in Kotoura Town, and all those
involved in their cooperation. We also thank Editage (www.​edita​ge.​com) for
the English language editing.

Kouzuki et al. BMC Geriatrics(2023) 23:397

Authors’ contributions
MK, NT, and KU designed the study. MK, NT, and MM performed tests. MK andNT analyzed and MK, NT, and KU interpreted the data. MK wrote the first draftof the manuscript and MM, NT, and KU reviewed it. All authors have read andapproved the final manuscript.
Funding
This study was supported by JSPS KAKENHI (Grant No. JP20K07886). The funding body had no role in the design of the study, data collection, analysis, orinterpretation of the data, or writing of the manuscript.
Availability of data and materials
The datasets used and/or analyzed during the current study are available fromthe corresponding author upon reasonable request, subject to the approval of
all authors and the ethics committee.

Declarations
Ethics approval and consent to participate
The Ethics Committee of Tottori University Faculty of Medicine (Yonago,
Japan) approved the design of this study (No. 20A227), which was conductedin accordance with the tenets of the Declaration of Helsinki. The research
protocol was explained to the participants, who provided written informed
consent.
Consent for publication
Not applicable.
Competing interests
MK, NT, and MM have no conflicts of interest. KU owns a patent on thecomputerized test battery for Alzheimer’s disease screening (produced by
Nihon Kohden Corporation, named monowasure soudan proguramu (MSP)(forgetfulness consultation program)) and receives royalties from Nihon
Kohden Corporation.
Author details
1
Department of Biological Regulation, School of Health Science, Facultyof Medicine, Tottori University, 86 Nishi‑Cho, Yonago 683‑8503, Japan. 2 Department of Dementia Prevention, School of Health Science, Faculty of Medicine,
Tottori University, 86 Nishi‑Cho, Yonago 683‑8503, Japan.
Received: 15 November 2022 Accepted: 19 June 2023

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