951396

research-article2020

APHXXX10.1177/1010539520951396Asia Pacific Journal of Public HealthKimura et al

Short Communication

Allaying Post-COVID-19 Negative
Health Impacts Among Older People:
The “Need To Do Something With
Others”—Lessons From the Japan
Gerontological Evaluation Study

Asia Pacific Journal of Public Health2020, Vol. 32(8) 479­–484© 2020 APJPHArticle reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/1010539520951396
DOI: 10.1177/1010539520951396
journals.sagepub.com/home/aph

Miyako Kimura, PhD1 , Toshiyuki Ojima, PhD2,
Kazushige Ide, PhD3,4, and Katsunori Kondo, PhD3,5
BackgroundOlder people are considered the most vulnerable population in the current COVID-19 (coronavirus disease-2019)
pandemic. While the negative impacts on health in thepresent are important, negative impacts on future healthshould also be considered. During the COVID-19 pandemic, older people have had more restrictions placed onthem. This includes restrictions on going out, meetingother people, and participating in activities, all of which
may negatively affect their social relationships.
The Japan Gerontological Evaluation Study (JAGES)
has collaborated with more than 40 municipalities throughout Japan and has promoted evidence-based, gerontologicalresearch, targeting approximately 300 000 adults aged 65
years and older. To mitigate post-COVID-19 negative healthimpacts among older people, this article presents the resultsof JAGES, and discusses the importance of social relationships on the health of older people.

Indirect Negative Health Impacts of
COVID-19 on Older People
First, since the COVID-19 pandemic may increase social
isolation among older people, opportunities for contact withothers should be maintained, with special attention paid tofrequency of contact (Table 1). According to Saito et al,1older people who were in contact with others “from once amonth to less than once a week” demonstrated a 1.40 times
increase in the risk of functional disability, a 1.39 times
increase in the risk of dementia, and a 1.15 times increase in
the risk of premature death, when compared with individuals
who reported they were in contact with others “frequently,
every day (more than 9 per week).” Moreover, older people
who were in contact with others “less than once a month”
demonstrated a 1.37 times increase in the risk of functional
disability, a 1.45 times increase in the risk of dementia, and a
1.34 times increase in the risk of premature death, whencompared with individuals who were in contact with others“frequently, every day.” Similar results were also seen in astudy by Aida et al.2 Therefore, to reduce the negative impact
of COVID-19 on health among older people, contact withothers at least once a week should be needed.
Second, while eating a healthy, balanced diet may bechallenging during the COVID-19 pandemic, not only nutrition but eating status among older people should also be considered. According to Tani et al,3 compared with older males
who ate with others, older males who ate alone and lived
alone were 2.36 times more likely to demonstrate the onset
of depression, while those who ate alone, but lived with others were 1.03 times more likely to develop depression.
Similarly, compared with older females who ate with others,
those who lived alone and ate alone were 1.31 times more
likely to develop depression, while those who ate alone, but
lived with others demonstrated a 1.21 times higher risk forthe onset of depression.3 These results indicate that eating
alone may increase the risk of depression, especially whencombined with living alone, in older males. During the
COVID-19 pandemic, older people living alone should
receive special consideration, as they may face difficulties ingoing to restaurants or having lunches/dinners with others.
Thus, the creation of opportunities to eat and communicate
with others through virtual lunches and dinners should beconsidered.

1

St. Marianna University, Kanagawa, Japan
Hamamatsu University School of Medicine, Shizuoka, Japan
3
Chiba University, Chiba, Japan
4
Hasegawa Hospital, Chiba, Japan
5
National Center for Geriatrics and Gerontology, Aichi, Japan
2

Corresponding Author:
Miyako Kimura, Department of Preventive Medicine, St. Marianna
University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-shi,
Kanagawa 216-8511, Japan.
Email: mkimura@marianna-u.ac.jp

480

Followed-up
from 2003 to2013

Followed-up
from 2003 to
2008

Followed-up
from 2010 to2013

Followed-up
from 2003 to2013

Followed for3436 days (9.4
years) from
2003

Saito et al1

Aida et al2

Tani et al3

Nemotoet al4

Saito et al5

StudyYears ofcollected data by
JAGES

13 98413 85037 19313 31012 085N(Analyze)

Incident dementia

Dementia onset

Depression

Mortality

Onset of functional
disability, dementia,
death

Outcomes

Sex, age, educational attainment,household income, depression,
subjective cognitive
impairment, IADL, walking
time, stroke, diabetes, hobby

Age, education, equivalised
household income, disease
symptom, higher level offunctional ability, frequency
of vegitable or fruit intake,
BMI, social support, social
participation, frequency ofmeet friends, employment
status, and marital status
Sex, age, educational attainment,
marital status, living status,
employment, drinking,smoking, walking time,
IADLs, medical history (heartdisease, stroke, hypertension,
diabetes), and depression

Age, sex, BMI, self-rated health,present illness, smoking
history, drinking, exercise,annual equivalent income,educational attainmentAge, gender, marital status, living
status, educational attainment,
annual equivalent income,disease, memory loss, living
area

Adjusted variables

Table 1. Studies that Used Data From the JAGES (published 2011-2020)a.

Social participation (neighborhood
associations/senior citizen clubs/
fire-fighting teams, hobby groups,
sports groups or clubs, politicalorganizations or groups, industrial
or trade associations, religious
groups, volunteer groups, andcitizen or consumer groups),
position in the organization(leadership positions or regularmembers)
Social relationship: social networks(contact with friends, marital
status), social support (social
support exchange), social activity(participating in community groupand engagement in paid work)

Cognitive social capital (generaltrust, social support, reciprocity)and structural social capital (social
network: participation in political,
industry, volunteer, citizen,
religious, sports, neighborhood,
avocation group, and frequency of
meeting friends)
Eating status, living status

Social isolation (frequency of faceto-face, non-face-to-face contact
with nonresident family members,
relatives, and friends)

Explanatory variables(continued)

Being married, exchanging support with family
members, having contact with friends, participatingin community groups, and engaging in paid work
were negatively related to incident dementia, after
adjusting for covariates. The diversity scores (range0-5) were associated with incident dementia(P < .001), and those who scored the highest were
46% less likely to develop incident dementia thanthose in the lowest category.

In young-old elderly (65-74 years), adjusted HR for
dementia onset (ref. nonparticipants): Regularmembers or leadership positions: adjusted HR:
0.75: 95% CI: 0.64-0.88. Adjusted HR for dementia
onset (ref. regular member): nonparticipants:
adjusted HR: 1.22, 95% CI: 1.02-1.46; Leadership
positions: HR: 0.81, 95% CI: 0.65-0.99.

The ARR for depression onset: Male: Those living
alone and eating alone: ARR: 2.36 (95% CI: 1.184.71); those living with others and eating alone:
ARR: 1.03 (95% CI: 0.81-1.32).
Female: Those living alone and eating alone: ARR:
1.31 (95% CI: 1.00-1.72); those living with othersand eating alone:
ARR: 1.21 (95% CI: 1.01-1.44).

HRs for functional disability, dementia, andpremature death (ref. contact with others morethan 9 per a week): Contact with others “lessthan once a month”: adjusted HR: 1.37, 95% CI:
1.16-1.61, HR: 1.45, 95% CI: 1.21-1.74, and HR:
1.34, 95% CI: 1.16-1.55, respectively. Contact withothers “from once a month to once a week” wasalso associated with these health indicators.
Low friendship network had significant association
with high all-cause mortality. Male: meeting friends
rarely (HR: 1.30, 95% CI: 1.10-1.53), female: having
no friends (HR: 1.81, 95% CI: 1.02-3.23), after
adjusting for covariates.

Results481

Followed-up
from 20102012 to 2016

Followed up
from 20102012 to 2013

Followed -up forabout 6 years
from 2010

Tsuji et al6

Fujihara
et al7

Ide et al8

StudyYears ofcollected data by
JAGES

Table 1. (continued)

47 30630 58740 308N(Analyze)

Incidence offunctional decline

IADL

Risk of cognitive
impairment

Outcomes

Age, sex, annual equivalent
income, educational
attainment, marital status,
self-reported medical
conditions, smoking, drinking,walking time, frequency ofgoing outdoors, depression,
emotional support,
instrumental support,frequency of meeting friends,
IADL

Sex, age, disease status
in treatment (stroke,
hypertension, diabetes, hearingloss), depression, educational
attainment, annual equivalent
income, the presence of
illnesses, depression, BMI,
smoking, drinking, daily walking
time, contact with others,
frequency of meeting withfriends/acquaintances, living
status, population density,
sunlight hours
Sex, age, marital status,
educational attainment,
annual household income,the presence of illnesses,
depression, BMI, smoking,drinking, daily walking time,
frequency of going outside

Adjusted variables

Social participation (neighborhoodgroups, hobby groups, sports
groups or clubs, industrial groups,
volunteer groups, and seniorcitizen clubs, work)

Main predictor variable: Communitylevel social capital: civic
participation (ie, participation in avolunteer group, a sports group, ahobby activity), social cohesion (ie,community trust and attachment),
reciprocity (ie, receiving/providing
emotional support or receiving
instrumental support). Predictor
variable: Individual-level social
capital: participation in civic life,social cohesion, reciprocity.

Frequency of sports group
participation

Explanatory variables(continued)

For rural and urban older people, participation inwork (Rural: HR: 0.83; 95% CI: 0.76-0.91, urban:
HR: 0.80; 95% CI: 0.70-0.91), participation in
hobbies (Rural: HR: 0.76; 95% CI: 0.68-0.85, Urban:
HR: 0.90; 95% CI: 0.84-0.97), and sports (Rural:
HR: 0.79; 95% CI: 0.69-0.89, Urban: HR: 0.83;
95% CI: 0.77-0.91) was found to be protective
against the incidence of decline, after adjusting forcovariates.

Older people living in a community with higher civic
participation presented significantly lower IADL
disability (odds ratio: 0.90 per 1 standard deviation
increase in civic participation score, 95% CI: 0.840.96), after adjusting for covariates.

Higher prevalence of community-level sports group
participation was associated with a lower risk ofcognitive impairment (adjusted HR: 0.92; 95% CI:
0.86-0.99, estimated by 10 percentage points ofparticipation proportion).

Results482

Followed-up
from 2003 to
2007

Followed -up
from 2003 to2013

Kanamori
et al10

Takahashi
et al119741

12 951

11 581N(Analyze)

The need for LTC
or death at theend of the 9.4
years observational
period, theincidence of theneed for LTC ordeath at 2 and 5
years

Incident functional
disability

Incident functional
disability

Outcomes

Age, gender, living alone,
educational attainment,smoking, drinking, walking
time, annual householdincome, the number ofcomorbidities

Age, sex, annual equivalent
income, educational
attainment, marital status,
occupational status, selfreported medical conditions

Age, sex, annual equivalent
income, educational
attainment, marital status,
occupational status, selfreported medical conditions,depression, smoking, drinking

Adjusted variables

Social participation (neighborhood
associations/senior citizen
clubs/fire-fighting teams, hobby
groups, sports groups or clubs,
political organizations or groups,
industrial or trade associations,religious organizations or groups,
volunteer groups and citizen or
consumer groups): the number oforganizations for participations;types of the organizations
Social participation (neighborhood
associations/senior citizen clubs/
fire-fighting teams, hobby groups,
sports groups or clubs, politicalorganizations or groups, industrial
or trade associations, religiousorganizations or groups, volunteer
groups, and citizen or consumer
groups)Frequency of exercise (sports
activities) and participation in
sports organization

Explanatory variables

Social participation was strongly related to lower
risk of the need for LTC (AOR: 0.82, 95% CI: 0.690.97) or death (AOR: 0.78, 95% CI: 0.70-0.88)

HRs for the incidence of functional disability (ref.
active participation group, doing exercise oncea month or more with participation in sportorganization): Exercise alone group (doing exercise
once a month or more without participation in sportorganization): adjusted HR: 1.29, 95% CI: 1.02-1.64.
Sedentary group (doing exercise less than once amonth without participation in sport organization):adjusted HR: 1.65, 95% CI: 1.33-2.04.
HRs for the incidence functional disability(ref. No participation): 1 participation:
HR: 0.83, 95% CI: 0.73-0.95; 2 participation:
HR: 0.72, 95% CI: 0.61-0.85; 3 or moreparticipation: HR: 0.57, 95% CI: 0.46-0.70)

Results

Abbreviations: JAGES, the Japan Gerontological Evaluation Study; HR, hazard ratio; CI, confidence interval; BMI, body mass index; ARR, adjusted rate ratio; IADL, instrumental activities of daily living, LTC, long-term care;
AOR, adjusted odds ratio.
a
In JAGES, we selected only larger studies (where the baseline survey included more than 10 000 participants) and those published after 2010 for the purpose of our study.

Followed-up
from 2003 to
2007

Kanamori
et al9Study

Years ofcollected data by
JAGES

Table 1. (continued)

Kimura et al
Third, while social gatherings increase the risk of spreading the coronavirus, the benefits of social participation
should also be taken into account. Using data from JAGES,
various studies have presented the relationships between
increased social participation and health, such as a decreased
risk of dementia,4,5 and cognitive impairment,6 increased
instrumental activities of daily living scores,7 decreased incidence of functional disability,8-11 and death.11 For example,
Kanamori et al,10 found that older people who participated in
one group demonstrated a 0.83 times lower incidence of disability, while those who participated in two groups demonstrated a 0.72 times, and those who participated in three ormore different types of groups demonstrated a 0.57 times
lower risk of disability than those who did not participate inany group. Similarly, Ide et al8 reported that the number ofgroups an older adult participated in was associated withlowered risk of functional decline in both rural and urban
areas (0.76-0.92 times lower risks than those who did notparticipate in any group). Furthermore, compared with theactive participant group (ie, exercising once a month or
more, and participation in a sports organization), the sedentary group (ie, exercising less than once a month and no participation in a sports organization) exhibited a 1.65 times
increase in risk, while the exercise-alone group (ie, exercising once a month or more and no participation in a sports
organization) demonstrated a 1.29 times increased risk forincidence of functional disability.9 In other words, while regular exercise may reduce the incidence of functional disability, participation in a sports organization increases thepreventive effects. Taken together, the above research suggests that participation in social activities is beneficial for
health, and that if older people lose such opportunities forextended periods of time, their health may be negatively
affected. Thus, the maintenance of social participation
among older people during the pandemic is a critical healthissue.

Conclusions and Recommendations
The COVID-19 pandemic has restricted people’s lives, andits impact on health may be prolonged. This article has discussed the impact of social relationships on health amongolder people, based on cohort studies of JAGES, from a“super-aging” society. To ameliorate negative health impacts
among older people post-COVID-19, these individuals
should be encouraged to contact others, eat with others, andmaintain organized social participation by practicing physicaldistancing. During mandated isolation, a minimum of weekly
contact with others is recommended. Even non-face-to-facemethods of contact could be beneficial, such as telephone,text, and/or video chat. Additionally, while eating with others
and maintaining social participation in organized groups inperson may be difficult during a pandemic, participation

483
could still occur via the internet. However, since internet use
may be challenging for some older people, the construction oftechnological support networks may be needed. Avoiding
pandemics such as COVID-19 may be impossible, but social
relationships may help minimize the associated health risks
in older individuals.
Author Contributions
Writing—original draft preparation, MK; review and editing, TO,
KK, and KI; supervision, TO and KK; project administration, KK.
All authors have read and agreed to the published version of themanuscript.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This study
was supported by Japan Society for the Promotion of Science
KAKENHI (JP20H00557, JP18H03047, JP17H02612), the Researchand Development Grants for Longevity Science from Japan Agency
for Medical Research and Development (AMED; JP19dk0110034,
JP20dk0110034), the Research Funding for Longevity Sciences from
National Center for Geriatrics and Gerontology (20-1, 20-19)

ORCID iD
Miyako Kimura

https://orcid.org/0000-0002-2833-3777

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