Preventive Medicine Reports 26 (2022) 101741

Contents lists available at ScienceDirect

Preventive Medicine Reports
journal homepage: www.elsevier.com/locate/pmedr

The number of leisure-time activities and risk of functional disability
among Japanese older population: the JAGES cohort
Yoshihiro Fuji a, b, Ryoto Sakaniwa a, Kokoro Shirai a, Tami Saito c, Shigekazu Ukawa d,
Hiroyasu Iso a, *, Katsunori Kondo e, faPublic Health, Department of Social Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan, 2-2 Yamadaoka, Suita-shi, Osaka 565-0871 Japan
Department of Rehabilitation, Osaka General Medical Center, Osaka, Japan, 3-1-56, Sumiyoshi-ku, Osaka-shi, Osaka 558-8558, Japan
Department of Social Science, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Aichi, Japan, 7-430, Morioka-cho, obu-shi,
Aichi 474-8511, Japand
Osaka City University Graduate School of Human Life Science, Osaka, Japan, 3-3-138, Sugimoto, Sumiyoshi-ku, Osaka-shi, Osaka 558-8585, Japane
Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba, Japan, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba
260-0856, Japanf
Department of Gerontological Evaluation, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Aichi, Japan, 7-430, Morioka-cho,obu-shi, Aichi 474-8511, Japanbc

A R T I C L E I N F O

A B S T R A C T

Keywords:
Leisure-time activities
Functional disability
Older population
Lower-loading
Prospective study

Evidence-based prevention of functional disability is a pressing issue for the health among the older population,
due to the rapidly global aging. This study aimed to examine the association between leisure-time activities andthe risk of functional disability. In a longitudinal prospective cohort study, we recruited 50,286 Japanese men
and women aged ≥ 65 years who did not have functional disability at the baseline in 2010–2011, with a medianfollow-up of 5.8 years. We examined the association between 24 leisure-time activities and the risk of developing
functional disability. Cox proportional hazards regressions were used to examine the hazard ratios (HRs) and
95% confidence intervals (95% CIs) for functional disability. A total of 10,631 persons (4,497 men and 6,134
women) newly developed functional disability. The number of leisure-time activities was inversely associatedwith the risk of functional disability. With reference to no activity, the multivariable HRs (95% CIs) were0.89 (0.82–0.97) for one activity, 0.72 (0.67–0.78) for two to four activities, and 0.66 (0.58–0.74) for five or
more activities (P for trend, <0.001) for men, and for women, the corresponding HRs were 0.84 (0.78–0.90),
0.77 (0.72–0.82), and 0.70 (0.62–0.79), (P for trend, <0.001). Further, even lower-loading leisure-time activ­
ities such as computer for men and handicrafts for women, were also associated with a reduced risk of functional
disability. Our study suggests the importance of engaging in various leisure-time activities among the older
population.

1. Introduction

Health, Labour and Welfare). Worldwide, the number of years lived withdisability doubled from 17.7 million in 1990 to 34.4 million in 2019
(Vos et al., 2020).
The association of leisure-time activities and health benefits among
the older population has been described based on the levels ofphysical activity (Corbett et al., 2018; Chen et al., 2016). For instance,
within a median follow-up of 11.6 years, the New Integrated Subur­
ban Seniority Investigation (NISSIN) of 2,888 Japanese men aged ≥ 65
years showed that leisure-time activity with ≥ 18 metabolic equivalent(MET) hours/week of leisure-time activities was associated with aFunctional disability are not a natural consequence of aging andcould be prevented in primary healthcare settings (Yates and Muchisky,
1997; WHO, 2008). Evidence-based prevention of functional disability isa pressing issue for the health among the older population, particularly
due to the rapidly aging population in several Asian countries (WHO,2017; eurostat Statistics Explained). In Japan, the annual medical costs
for managing patients with functional disability are expected to increase
from US $ 100 billion in 2018 to US $ 150 billion by 2025 (Ministry of* Corresponding author. Tel.: +81-6-6879-3911.
E-mail addresses: jzx90.mark23669@gmail.com (Y. Fuji), r.sakaniwa@pbhel.med.osaka-u.ac.jp (R. Sakaniwa), kshirai@pbhel.med.osaka-u.ac.jp (K. Shirai), tsaito@ncgg.go.jp (T. Saito), ukawa@life.osaka-cu.ac.jp (S. Ukawa), iso@pbhel.med.osaka-u.ac.jp (H. Iso), kkondo@kkondo.net (K. Kondo).
https://doi.org/10.1016/j.pmedr.2022.101741
Received 8 September 2021; Received in revised form 14 February 2022; Accepted 16 February 2022
Available online 19 February 2022
2211-3355/© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).

Y. Fuji et al.

Preventive Medicine Reports 26 (2022) 101741

including a physician’s examination and evaluation of physical andcognitive functions (Tsutsui and Muramatsu, 2005). Functional dis­abilities were assessed with seven levels: support needed (levels 1 to 2),
care needed (levels 1 to 5), or no functional disability (independent). Allregistered individuals who were identified with functional disability
received public and social welfare services for adult day care, home-visit
care, day-visit services, short-stay services, residential services, and/or
in-facility services, depending on the degree of functional disabilities
from local government (Ministry of Health, Labour and Welfare). These
LTCI’s criteria are widely adopted in previous epidemiological studies(Kanamori et al., 2014; Ukawa et al., 2020; Hikichi et al., 2015; Ashida
et al., 2016; Aida et al., 2013). In each, local Japanese government, theapplicants for the LTCI are asked to fill out a basic application form
(Ministry of Health, Labor and Welfare, 2013).
Information on all-cause mortality was obtained from the LTCI
database system of the participants’ municipality office. Those who diedfrom any cause, moved out from their original community, or had nodata on the last follow-up, whichever came first, were censored.

reduced risk of functional disability compared with no leisure-time ac­tivities (multivariable hazard ratio [HR]: 0.48; 95% confidence interval[CI]: 0.25–0.94) (Matsunaga et al., 2017). A 10-year follow-up pro­
spective study of 2,456 Finnish men and women aged ≥ 65 years showedthat participation in intensive sports and training for ≥ 3 h/week wereassociated with a reduced risk of incident cardiovascular disease (cor­onary heart disease and stroke) compared with non-intensive leisuretime activities (HR: 0.55, 95% CI: 0.38–0.79) (Barengo et al., 2017).
The Bronx aging study of 469 English men and women aged ≥ 75
years reported that many of the older adults participated two or moretypes of leisure-time activities such as playing board games (22.6%),
reading books (81.4%), writing (18.6%), performing housework(77.4%), walking (86.1%), climbing the stairs (67.4%), andparticipating in group exercise (30.0%) (Verghese et al., 2003).
Therefore, the impact of the number of various leisure-time activities
on the risk of functional disability should be taken into account.
Previous studies reported the benefit of the number of leisure-time
activities on the risk of all-cause mortality (Kobayashi et al., 2021),
dementia (Xu et al., 2017; Ling et al., 2020), and cognitive impairments
among individuals aged ≥ 65 years (Doi et al., 2017; Sugita et al., 2020).
Other studies reported that the number and frequency of social partic­
ipations in leisure-time activities were associated with a lower risk offunctional disability (Kanamori et al., 2014; Komatsu et al., 2019).
However, the association between the number of different types ofleisure-time activities such as walking/running, and gardening,
traveling and the risk of functional disability has not been investigated.
This prospective cohort study aimed to examine the association be­
tween the number of various leisure-time activities and the risk offunctional disability in 50,286 Japanese individuals aged ≥ 65 years.

2.3. Definition of the number of leisure-time activities
At baseline, all participants were asked the following question: “Do
you currently have any leisure-time activities?” When the participants
responded “yes,” they were asked to provide the different types ofleisure-time activities that they engaged in.
According to physical activities tracking guide, the amount of timespent (in METs) in performing leisure-time activities were as follows: forexample walking/running: 2.3/6.0, gardening: 3.3, traveling: 2.5,
reading: 1.3, computer: 1.5, and handicrafts: 1.3 (Ainsworth et al.,2011). The types of leisure-time activities were classified as: higherloading leisure-time activities (METs ≥ approximately 2.5: walking/running, gardening, traveling, cultivation of agricultural crops, karaoke,
fishing, golf, photography, grand golf, exercise/tai chi, mountainclimbing, instrument performance, gate ball, dance, and chorus/folksong) and lower-loading activities (METs < 2.5: reading, computer, igo/shogi/mahjong, pachinko, painting/picture letter, calligraphy, haiku/
tanka/senryu, handicrafts, and tea ceremony/flower arrangement), andother non-specified activities.
We counted the total number of leisure-time activities performed byeach individual (from 0 to 24 points). All participants were divided into
four groups according to the number of leisure-time activities (zero, one,
two to four, and ≥ five or more types).

2. Methods
2.1. Study population
We used the data from the JAGES (Japan Gerontological Evaluation
Study) cohort. The study profile has been described elsewhere (Kondo,
2016; Kondo and Rosenberg, 2018). In brief, the baseline mail survey
was conducted in 2010–2011 using a self-administered questionnaire. A
total of 54,539 people (25,146 men and 29,393 women) aged ≥ 65 years
without functional disability from 31 municipalities in Japan wereenrolled in our study. We excluded 48 individuals who did not respondto our survey and 4,204 individuals with missing data on leisure-time
activities. Finally, 50,286 (23,103 men and 27,183 women) in­
dividuals were included in the current study. Data on the incidence offunctional disability from 2010 to 2016 were obtained from municipal
public long-term care insurance (LTCI) system databases, and we iden­tified people who were newly eligible for the LTCI benefit considered as
those with functional disability.
This study was ethically approved by the institutional review boards(no. 10–05, no. 1777). All respondents were informed that participationin this study was absolutely voluntary and that completing and return­ing the questionnaires via mail indicated their consent to participate.

2.4. Covariates
The sociodemographic variables (sex, age, and marital status), so­
cioeconomic status (educational level, occupational status, and equiv­
alized income), health-related behaviors (smoking status, IADL status,
and walking hours), and histories of comorbidities (diabetes mellitus,
hypertension, stroke, heart disease, mental disorder, and hearing loss),engagement in social activities (political groups/organizations, volun­teer groups, sports groups/clubs, neighborhood associations, and seniorclubs), and frequency of meeting friends were included as covariates for
multivariate-adjusted examinations. These variables were divided into
the following categories: sex (men or women), age (65–69, 70–74,
75–79, 80–84, or ≥ 85 years), educational level (<10 or ≥ 10 years),
occupational status (employed or not employed), equivalized income(<200, 200–399, or ≥ 400 × 10,000 JPY; 100 JPY≒1 USD), marital
status (married, widowed, divorced, or never married), smoking status(yes or no), IADL status (independent; 5 points out of 5 or notindependent; <5 points) (Koyano et al., 1991), walking hours (<30,
30–59, 60–89, ≥90 min/day), and histories of comorbidities (diabetes
mellitus, hypertension, stroke, heart diseases, mental disorder, and/or
hearing loss), social activities (political groups/organizations, volunteer
groups, sports groups/clubs, neighborhood associations, and/or seniorclubs), and frequency of meeting friends (≥four or more times/week,

2.2. Definition for functional disability
The follow-up period started from August 2010 until April 2016,
with the longest being 2,070 days. Older adults in Japan with functional
disability were certified for LTCI database (Ministry of Health, Labourand Welfare). A formal evaluation was conducted to determine the levelof LTCI services for older adults with functional disability (Tsutsui and
Muramatsu, 2005; Tsutsui and Muramatsu, 2007). This system wasapplied as public and social welfare services throughout Japan andcovers aged ≥ 65 years with limitations in performing ADL and/or
instrumental ADL (IADL) regardless of their income status. The levels offunctional disability were assessed by certified interviewers throughhome-visited and based on written opinions from a primary physician,2

Y. Fuji et al.

Preventive Medicine Reports 26 (2022) 101741

Table 1
Sex-specific baseline characteristics according to the number of leisure-time activities
Men

Women

Number of leisure-time activities (%)
Number at risk, n*Age, years**
Educational level, years**>10

Occupational status**

Not employed

Equivalized income, 10,000 JPY*

<200
200–399>400

Marital status*

MarriedWidowedDivorced
Never married

Smoking status*

Current
FormerNever

Instrumental activities of daily living (IADL) status**

Independent; 5 points out of 5
Not-independent; less than 5points

Walking hours, min/day*<30
30− 5960− 89>90

History of diabetes mellitus

Yes

History of hypertension

Yes

History of stroke

Yes

History of heart disease

Yes

History of mental disorder**Yes

History of hearing loss**

Yes

Political groups/organizations**

Yes

Volunteer groups**

Yes

Sports groups/clubs**

Yes

Neighborhood associations**

Yes

Senior clubs**

Yes

Frequency of meeting friends*>4 times/week
2–3 times/week
1 time/week
1–2 times/monthless than 1 times/year

3

Number of leisure-time activities (%)

0

1

2− 4

>5

0

1

2− 4

>5

6,503
(28.2)
74.2
(6.4)
1,797
(27.6)
3,886(59.8)
1,395(21.5)
3,483(53.6)
652(10.0)
5,416(83.3)
589
(9.1)
201
(3.1)
131
(2.0)
1,417
(21.8)
2,405(37.0)
1,488(22.9)
3,597(55.3)
2,594(39.9)
2,704(41.6)
1,884(29.0)
802(12.3)
920(14.2)
980(15.1)
2,429(37.4)
160
(2.5)
981
(15.1)
81
(1.3)
564
(8.7)
130
(2.0)
239
(3.7)
131
(2.0)
497
(7.6)
322
(5.0)
667
(10.3)
791(12.2)
772(11.9)
1,195(18.4)
2,734(42.1)

3,848(16.6)
74.7
(6.3)
1,000
(26.0)
2,387(62.0)
832(21.6)
1,980(51.5)
425(11.0)
3,187(82.8)
370
(9.6)
122
(3.2)
63
(1.6)
834
(21.7)
1,409(36.6)
954(24.8)
2,254(58.6)
1,412(36.7)
1,534(39.9)
1,124(29.2)
509(13.2)
585(15.2)
582(15.1)
1,446(37.6)
90(2.3)
570(14.8)
33
(0.9)
325
(8.5)
153
(4.0)
188
(4.9)
465
(12.1)
350
(9.1)
313
(8.1)
486
(12.6)
615(16.0)
590(20.5)
700(18.8)
1,286(33.5)

9,429(40.8)
73.6
(5.7)
3,270
(34.7)
6,313(67.0)
1,388(14.7)
5,559(59.0)
1,516(16.1)
8,170(86.7)
776
(8.2)
209
(2.2)
117
(1.2)
1,658
(17.6)
4,161(44.1)
2,237(23.7)
6,626(70.3)
2,415(25.6)
2,666(28.3)
3,368(35.7)
1,668(17.7)
1,626(17.2)
1,415(15.0)
3,594(38.1)
162
(1.7)
1,353
(14.4)
53
(0.6)
701
(7.4)
398
(4.2)
971
(10.3)
2,249(23.9)
1,307(13.9)
1,206(12.8)
1,212(12.9)
1,937(20.5)
1,589(16.9)
2,023(21.5)
2,441(25.9)

3,323(14.4)
73.0
(5.3)
1,201
(36.1)
2,422(72.9)
309
(9.3)
2,082
(62.7)
728(21.9)
2,991(90.1)
223
(6.7)
61
(1.8)
23
(0.7)
417
(12.6)
1,693(51.0)
826(24.9)
2,724(82.0)
497(15.0)
524(15.8)
1,303(39.2)
745(22.4)
730(22.0)
491(14.8)
1,245(37.5)
59(1.8)
460(13.8)
23
(0.7)
209
(6.3)
178
(5.4)
657
(19.8)
1,370(41.2)
704(21.2)
579(17.4)
492(14.8)
833(25.1)
634(19.1)
744(22.4)
123(17.4)

9,071(33.4)
75.1
(6.7)
2,409
(26.6)
5,586(61.6)
2,012(22.2)
3,883(42.8)
712
(7.9)
4,892
(53.9)
3,265(36.0)
389
(4.3)
190
(2.1)
383
(4.2)
334
(3.7)
6,860
(75.6)
6,274(69.2)
2,479(27.3)
3,726(41.1)
2,616(28.8)
1,017(11.2)
1,104(12.2)
1,048(11.6)
3,775(41.6)
85(0.9)
994(11.0)
138
(1.5)
731
(8.1)
103
(1.1)
204
(2.3)
115
(1.3)
306
(3.4)
509
(5.6)
1,233
(13.5)
1,676(18.5)
1,310(14.4)
1,705(18.8)
2,447(27.0)

4,591(16.9)
75.2
(6.3)
1,318
(28.7)
2,857(62.2)
990(21.6)
1,899(41.4)
434
(9.5)
2,501
(54.5)
1,626(35.4)
168
(3.7)
113
(2.5)
164
(3.6)
154
(3.4)
3,529
(76.9)
3,474(75.7)
956(20.8)
1,771(38.6)
1,437(31.3)
527(11.5)
563(12.3)
466(10.2)
1,931(42.1)
31(0.7)
464(10.1)
60
(1.3)
387
(8.4)
214
(4.7)
205
(4.5)
513
(11.2)
256
(5.6)
531
(11.6)
665(14.5)
1,082(23.6)
842(18.3)
909(19.8)
797(17.4)

10,491(38.6)
73.5
(5.7)
3,961
(37.8)
7,281(69.4)
1,662(15.8)
5,114(48.8)
1,561(14.9)
6,299(60.0)
3,318(31.6)
397
(3.8)
270
(2.6)
248
(2.4)
369
(3.5)
8,661
(82.6)
9,180(87.5)
966
(9.2)
3,126
(29.8)
3,743(35.7)
1,647(15.7)
1,602(15.3)
968
(9.2)
4,255
(40.6)
59
(0.6)
907
(8.7)
90
(0.9)
691
(6.6)
482
(4.6)
1,003
(9.6)
2,859
(27.3)
935
(8.9)
1,758
(16.8)
1,629(15.5)
3,221(30.7)
2,099(20.0)
1,964(18.7)
1,161(11.1)

3,030(11.2)
72.3
(5.0)
1,363
(45.0)
2,343(77.3)
329(10.9)
1,596(52.7)
664(21.9)
1,904(62.8)
931(30.7)
92
(3.0)
79
(2.6)
55
(1.8)
97
(3.2)
2,621
(86.5)
2,892(95.5)
70(2.3)
565(18.7)
1,176(38.8)
610(20.1)
617(20.4)
264
(8.7)
1,086
(35.8)
19
(0.6)
244
(8.1)
13
(0.4)
149
(4.9)
136
(4.5)
644
(21.3)
1,486(49.0)
447(14.8)
672(22.2)
584(19.3)
1,197(39.5)
582(19.2)
419(13.8)
169(5.6)

Y. Fuji et al.

Preventive Medicine Reports 26 (2022) 101741

All data are presented by means (standard deviations) or numbers (percentages).
*P for differences in proportions across the number of leisure-time activities: P < 0.001.
** P for trends in means and proportions across the number of leisure-time activities: P < 0.001.

3. Results

Table 2
Sex-specific the number (proportion) of higher-loading, lower-loading and othernon-specified leisure-time activities

Higher-loading leisure-time activities
Walking/Running
Gardening
Traveling
Cultivation of agricultural crops
KaraokeFishing
Golf
Photography
Grand golf
Exercise/Tai Chi
Mountain climbing
Instrument performance
Gate ball
Dance
Chorus/ Folk song
Lower-loading leisure-time activities
Reading
Computer
Igo/Shogi/Mahjong
Pachinko
Painting/Picture letter
Calligraphy
Haiku/Tanka/Senryu
Handicrafts
Tea ceremony/Flower arrangement
Other non-specified activities

Men

Women

Number (%)

Number (%)

6,119 (55.4)
5,675 (42.6)
5,354 (48.3)
3,118 (46.6)
2,660 (48.5)
2,488 (96.2)
2,381 (90.0)
2,170 (77.5)
2,162 (53.5)
827 (22.6)
654 (65.1)
465 (30.9)
370 (50.7)
312 (15.4)
217 (15.2)

4,936 (44.6)
7,653 (57.4)
5,742 (51.7)
3,572 (53.4)
2,826 (48.5)
99 (3.8)264 (10.0)
629 (22.5)
1,875 (46.5)
2,829 (77.4)
351 (34.9)
1,040 (69.1)
359 (49.3)
1,710 (84.6)
1,207 (84.8)

3,865 (50.4)
3,148 (75.9)
2,513 (91.8)
1,511 (74.3)
647 (33.1)
573 (31.1)
416 (37.6)
306 (7.5)
84 (6.4)
2,512 (43.5)

3,805 (49.6)
1,002 (24.1)
225 (8.2)
523 (25.7)
1,309 (66.9)
1,270 (68.9)
766 (62.4)
3,782 (92.5)
1,223 (93.6)
3,262 (56.5)

The participant’s mean ages at baseline were 73.9 years for men and74.2 years for women. The number of newly certified LTCI according to
the number of leisure-time activities and sex were as follows: 1,643 forno activity, 933 for one activity, 1,522 for two to four activities, and 399
for five or more activities in men, and 2,712, 1,189, 1,865, 368,
respectively in women.
Table 1 shows the sex-specific baseline characteristics according to
the number of leisure-time activities. In brief, younger individuals,
higher educational level, unemployed status, high IADL status, higher
current equivalized income, ≥30 walking hours, the participation inpolitical groups/organizations, volunteer groups, sports groups/clubs,
neighborhood associations, senior clubs, and frequency of meeting
friends were more prevalent in individuals with higher number ofleisure-time activities for both men and women. Meanwhile, never andformer smokers and histories of diabetes mellitus, stroke, heart diseases,
mental disorder, and hearing loss were inversely associated with thenumber of leisure-time activities for both men and women.
The proportion of each leisure-time activity according to the numberof leisure-time activities is summarized in Table 2. Many of theparticipants performed walking/running (6,119 men, 4,936 women),gardening (5,675 men, 7,653 women), traveling (5,354 men, 5,742
women), reading (3,865 men, 3,805 women), computer (3,148 men,
1,002 women), and handicrafts (306 men, 3,782 women) as leisuretime activities.
During a median follow-up of 5.8 years, 10,631 participants (4,497
men, 6,134 women) developed functional disability. The sex-specificHRs and 95% CIs for functional disability, according to the number ofleisure-time activities, are summarized in Table 3. The number ofleisure-time activities was inversely associated with the risk offunctional disability for both men and women even after adjustment
for potential confounding variables. In the final model (model 2), themultivariable HRs (95% CIs) for functional disability were as follows:
0.89 (0.82–0.97) for one activity, 0.72 (0.67–0.78) for two to four
activities, and 0.66 (0.58–0.74) for five or more activities (P for trend,<0.001) in men, 0.84 (0.78–0.90), 0.77 (0.72–0.82), 0.70 (0.62–0.79)(P for trend, <0.001), respectively in women. The dose–response
associations were not attenuated, after exclusion of early onsets offunctional disability from 1 to 3 years for both men and women (P for
trend, <0.001).
The HRs and 95% CIs for functional disability, according to higherand lower- loading leisure-time activities are summarized in Table 4.
The higher loading leisure-time activities were inversely associated withthe risk of functional disability even after adjustment for potential
confounding variables. The lower loading leisure-time activities alsotended to be inversely associated with the risk of functional disability.
The sex-specific associations between each leisure-time activities andthe risk of functional disability are shown in Supplementary Table 1. For
both men and women, traveling, cultivation of agricultural crops wereinversely associated with the risk of functional disability. An inverse
association was also observed between walking/running, computer,fishing, golf, mountain climbing and the risk of functional disability formen, and between gardening, instrument performance, dance, handi­
crafts and the risk of functional disability for women, but no significant
association was observed between other leisure-time activities and therisk for both men and women.

two to three times/week, one time/week, one to two times/month, lessthan one times/year).
2.5. Statistical analyses
Sex-specific differences in baseline characteristics according to thenumber of leisure-time activities were examined using the chi-square
test for categorical variables, one-way analysis of variance (ANOVA)
for continuous variables, and Cochran-Armitage test for variables
expressed as percentage. Cox proportional hazards regression was used
to calculate the HR and 95% CI of functional disability after controllingfor confounding variables. We also calculated the HR of functional
disability associated with higher- and lower- loading leisure-time ac­tivities, separately. The confounding variables for the multivariableadjustment in model 1 were age, educational level, occupational status,
equivalized income, marital status, smoking status, IADL status, walking
hours, histories of diabetes mellitus, hypertension, stroke, heart disease,mental disorder, and hearing loss. Model 2 was adjusted further forengagement in social activities of political groups/organizations,
volunteer groups, sports groups/clubs, neighborhood associations, se­nior clubs, and frequency of meeting friends. For participants withmissing data, we imputed “missing-variable” as covariate. All missing
data were considered as missing completely at random, and the numberof participants with missing data were generally small. Meanwhile,
functional disability that occurred from year 1 to year 3 were included in
the sensitive analysis to reduce the possibility of reverse causation. Pvalues ≤ 0.05 (two-sided tails) were considered as significant. All sta­tistical analyses were performed using SAS version 9.4 (SAS InstituteInc., Cary, NC, USA).

4. Discussion
In this large prospective cohort study of older men and women, we
found inverse associations between the number of leisure-time activities
4Y. Fuji et al.

Preventive Medicine Reports 26 (2022) 101741

Table 3Sex-specific hazard ratio (HR) and 95% confidence interval (CI) for functional disability according to the number of leisure-time activities
Men

Women

Number of leisure-time activities

Number of leisure-time activities

0

1

2− 4

>5

0

1

2− 4

>5

Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

6,503
30,604
1,643
Ref
Ref

Multivariable HRs2** (95%CIs)

Ref

Onset within 1 year excluded
Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

9,429
48,2791,522
0.61(0.57− 0.65)
0.69(0.64− 0.74)
0.72(0.67− 0.78)

3,323
17,464399
0.47(0.42− 0.52)
0.60(0.54− 0.67)
0.66(0.58− 0.74)

9,071
42,907
2,712
RefMultivariable HRs1* (95%CIs)

3,848
18,469933
0.86(0.79− 0.93)
0.87(0.80− 0.94)
0.89(0.82− 0.97)

4,591
22,6241,189
0.78(0.73− 0.84)
0.82(0.77− 0.88)
0.84(0.78− 0.90)

10,491
54,346
1,865
0.65(0.61− 0.69)
0.74(0.70− 0.79)
0.77(0.72− 0.82)

3,030
16,240368
0.52(0.47− 0.58)
0.65(0.58− 0.72)
0.70(0.62− 0.79)

5,159
26,194
1,344
Ref
Ref

Multivariable HRs2** (95%CIs)

Ref

Onset within 2 year excluded
Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

8,075
43,532
1,354
0.65(0.60− 0.70)
0.72(0.67− 0.78)
0.75(0.69− 0.81)

2,971
16,197352
0.49(0.44− 0.55)
0.61(0.54− 0.69)
0.66(0.58− 0.75)

6,882
35,7302,189
Ref

Multivariable HRs1* (95%CIs)

3,056
15,818792
0.89(0.81− 0.97)
0.89(0.82− 0.98)
0.91(0.84− 0.99)

3,570
19,124
1,021
0.82(0.76− 0.88)
0.86(0.80− 0.92)
0.87(0.81− 0.94)

8,870
48,741
1,621
0.68(0.63− 0.72)
0.77(0.72− 0.82)
0.79(0.73− 0.85)

2,707
15,081323
0.54(0.48− 0.61)
0.66(0.58− 0.75)
0.70(0.62− 0.80)

5,486
26,693
1,017
Ref
Ref

8,326
43,913
1,103
0.68(0.63− 0.74)
0.76(0.69− 0.83)
0.79(0.72− 0.87)

3,026
16,277297
0.53(0.46− 0.60)
0.65(0.57− 0.75)
0.70(0.61− 0.81)

7,387
36,480
1,684
RefMultivariable HRs1* (95%CIs)

3,234
16,082614
0.90(0.82− 0.99)
0.91(0.82− 1.00)
0.93(0.84− 1.02)

3,780
19,436811
0.83(0.76− 0.90)
0.87(0.80− 0.94)
0.88(0.81− 0.96)

9,186
49,2171,305
0.69(0.64− 0.74)
0.76(0.71− 0.82)
0.79(0.73− 0.85)

2,762
15,164268
0.56(0.49− 0.64)
0.66(0.58− 0.75)
0.71(0.61− 0.81)

3,385
16,460463
0.94(0.84− 1.06)
0.95(0.85− 1.07)
0.97(0.87− 1.09)

8,597
44,584832
0.70(0.63− 0.77)
0.78(0.70− 0.86)
0.81(0.73− 0.90)

3,099
16,460224
0.54(0.46− 0.62)
0.67(0.57− 0.78)
0.71(0.60− 0.83)

7,880
37,699
1,191
Ref

3,985
19,944606
0.87(0.79− 0.96)
0.90(0.82− 0.99)
0.91(0.82− 1.00)

9,537
50,094954
0.69(0.63− 0.75)
0.77(0.70− 0.83)
0.77(0.71− 0.85)

2,820
15,312210
0.59(0.51− 0.69)
0.69(0.59− 0.80)
0.72(0.61− 0.85)

2Multivariable HRs ** (95%CIs)

Ref

Onset within 3 year excluded
Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

5,767
27,394736
Ref

Multivariable HRs1* (95%CIs)

Ref

Multivariable HRs2** (95%CIs)

Ref

Ref
Ref

Ref
Ref

Ref
Ref

Ref
Ref

* Multivariable HRs1 were adjusted for age, educational level, occupational status, equivalized income, marital status, smoking status, instrumental activities of dailyliving (IADL) status, walking hours, histories of diabetes mellitus, hypertension, stroke, heart disease, mental disorder, and hearing loss.
** Multivariable HRs2 were adjusted further for sports groups/clubs, senior clubs, neighborhood associations, volunteer groups, political groups/organizations, andfrequency of meeting friends.
All of the P for trend were < 0.001.

and the risk of functional disability for both men and women. Comparedwith persons without leisure-time activities, those with one or moreleisure-time activities had reduced risk of functional disability in a
dose–response manner. These associations did not substantially change
after exclusion of early onsets of functional disability.
In a previous JAGES study conducted in 13,310 Japanese aged ≥ 65
years, social participation in three or more in hobby clubs, sports groups,
and local community activities were associated with a 43% lower risk offunctional disability compared with no social participation in the 4-year
follow-up (Kanamori et al., 2014). In another JAGES study conducted in
44,978 Japanese aged ≥ 65 years, the high frequency of social partici­
pation in both sports and the hobby and high frequency of social
participation in both political and industry/trade activities were asso­
ciated with reduced risks of functional disability by 34% and 29%,
respectively compared with the low frequency of social participation in
the 3-year follow-up (Ukawa et al., 2020). In a previous 3-year follow-up
study of 6,360 Japanese older adults, the participation in hobby clubs
was associated with a 32% reduced risk of functional disability for men
and a 47% reduced risk of functional disability for women comparedwith no social participation (Tomioka et al., 2017). These previous
studies, however, did not examine the association between the numberof leisure-time activities and risk of functional disability.
We found an association between functional disability and various
leisure-time activities such as traveling, cultivation of agricultural crops,
walking/running (men only), computer (men only), fishing (men only),golf (men only), mountain climbing (men only), and gardening (womenonly), instrument performance (women only), dance (women only),
handicrafts (women only). The guidelines by the Ministry of Health andLabour and Welfare, Japan recommend that older adults (aged ≥ 65
years) should perform at least 10 MET-hours/week of physical activity.
A prospective cohort study of 1,445 Japanese men aged ≥ 65 years
showed that persons who performed ≥ 18MET-hours/weeks of leisuretime activities had a 52% lower risk of developing functional
disability, compared with those who did not engage in leisure-time ac­tivities during 11.6 years median follow-up (Matsunaga et al., 2017). By
contrast, our study showed that even lower-loading leisure-time activ­
ities tended to be associated with a reduced the risk of functional
disability. We assume that lower-loading activities likely make older
people to be less physically fatigued, and to be continued as habits. Mostof lower-loading activities needs manual dexterity which was associatedwith a lower risk of mild cognitive impairment in 7-year follow-up of
1,160 older Americans (Beeri et al., 2021).
5

Y. Fuji et al.

Preventive Medicine Reports 26 (2022) 101741

Table 4
Hazard ratio (HR) and 95% confidence interval (CI) for functional disability according to the number of higher- and lower- loading leisure-time activities
Number of higher-loading leisure-time activities

Number of lower-loading leisure-time activities

0

1

2− 4

>5

0

1

2− 4

>5

Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

19,75993,310
5,460
Ref
Ref

Onset within 1 year excluded
Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

17,68092,8132,597
0.57(0.54− 0.59)
0.70(0.66− 0.73)

2,196
11,828242
0.46(0.41− 0.53)
0.66(0.58− 0.76)

31,987
157,643
7,489
Ref

Multivariable HRs (95%CIs)

10,561
52,9832,332
0.76(0.73− 0.80)
0.83(0.79− 0.87)

11,83360,1802,111
0.81(0.77− 0.85)
0.89(0.85− 0.94)

6,381
32,6611,017
0.74(0.70− 0.80)
0.88(0.82− 0.94)

85
450
14
0.74
(0.44− 1.24)
1.02(0.60− 1.72)

15,29178,648
4,468
Ref
Ref

Onset within 2 year excluded
Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

15,36084,6042,320
0.60(0.57− 0.63)
0.71(0.68− 0.75)

1,985
11,058211
0.47(0.41− 0.54)
0.65(0.56− 0.75)

25,714
136,444
6,273
Ref

Multivariable HRs (95%CIs)

8,654
46,1071,997
0.78(0.74− 0.83)
0.84(0.80− 0.89)

9,998
53,916
1,835
0.83(0.79− 0.87)
0.91(0.86− 0.96)

5,506
29,661875
0.75(0.70− 0.81)
0.88(0.82− 0.95)

72
397
13
0.80
(0.47− 1.38)
1.07(0.62− 1.85)

16,34580,219
3,414
Ref
Ref

Onset within 3 year excluded
Number at risk, nPerson-years
Number of cases, nAge-adjusted HRs (95%CIs)

15,767
85,2191,913
0.62(0.59− 0.66)
0.74(0.69− 0.79)

2,018
11,108178
0.50(0.43− 0.58)
0.67(0.57− 0.78)

27,060138,476
4,927
Ref

Multivariable HRs (95%CIs)

9,057
46,7171,594
0.81(0.76− 0.86)
0.86(0.81− 0.91)

10,381
54,481
1,452
0.83(0.78− 0.88)
0.91(0.85− 0.96)

5,674
29,910707
0.76(0.71− 0.83)
0.89(0.82− 0.96)

72
397
13
1.01
(0.59− 1.74)
1.31(0.76− 2.26)

17,296
82,582
2,463
Ref
Ref

16,24886,422
1,432
0.63(0.59− 0.67)
0.73(0.68− 0.78)

2,060
11,212136
0.50(0.42− 0.60)
0.65(0.54− 0.78)

28,385
141,760
3,602
Ref

Multivariable HRs (95%CIs)

9,466
47,732
1,185
0.82(0.77− 0.88)
0.87(0.81− 0.93)

10,76255,4401,071
0.83(0.78− 0.89)
0.91(0.85− 0.97)

5,848
30,344533
0.78(0.72− 0.86)
0.91(0.83− 1.00)

75
404
10
1.08
(0.58− 2.00)
1.38(0.74− 2.57)

Ref

Ref

Ref

Ref

Multivariable HRs were adjusted for sex, age, educational level, occupational status, equivalized income, marital status, smoking status, instrumental activities of dailyliving (IADL), walking hours, histories of diabetes mellitus, hypertension, stroke, heart disease, mental disorder, and hearing loss, sports groups/clubs, senior clubs,
neighborhood associations, volunteer groups, political groups/organizations, frequency of meeting friends.
All of the P for trend were < 0.001.

Our study has two strengths. First, we followed up over 50,000 older
adults for a median of 5.8 years. Second, the 24 types of leisure-time
activities were tested to examine the impact of the number of leisuretime activities on functional disability.
This study has several limitations. First, objective assessment forclinical diagnosis of functional disability was not conducted systemati­
cally at enrollment so that in some participants functional disability
might have existed in our study. Second, the reverse causation for the
association between leisure-time activities and the risk of functional
disability remained. However, the absence of substantial changes in theassociation after the exclusion of early onsets of functional disability
from the baseline up to 3 years suggested that the reverse causation may
be unlikely.

analysis, Writing – review & editing. Shigekazu Ukawa: Conceptuali­zation, Validation, Formal analysis, Writing – review & editing. Hir­oyasu Iso: Conceptualization, Supervision, Validation, Formal analysis,
Software, Writing – review & editing. Katsunori Kondo: Conceptuali­zation, Investigation, Validation, Formal analysis, Funding acquisition,
Project administration, Resources, Writing – review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement

5. Conclusion

We do not have the contribution of others who merit authorship andsponsor.

We found inverse dose–response associations between the number ofleisure-time activities including lower-loading activities and the risk offunctional disability among Japanese older men and women. Ourfinding suggests that engaging in various types of leisure-time activities
may contribute to the prevention of functional disability.

Funding
This study used data from JAGES (The Japan Gerontological Evaluation
Study). This study was supported by Grants-in-Aid for Scientific Research(15H01972, 15H04781, 15H05059, 15 K03417, 15 K03982, 15 K16181,
15 K17232, 15 K18174, 15 K19241, 15 K21266, 15KT0007, 15KT0097,
16H05556, 16 K09122, 16 K00913, 16 K02025, 16 K12964, 16 K13443,
16 K16295, 16 K16595, 16 K16633, 16 K17256, 16 K17281, 16 K19247,
16 K19267, 16 K21461, 16 K21465, 16KT0014, 16KK0059, 17 K04305,
17 K34567, 17 K04306, 25253052, 25713027, 26285138, 26460828,
26780328, 18H03018, 18H04071, 18H03047, 18H00953, 18H00955,
18KK0057, 19H03901, 19H03915, 19H03860, 19 K04785, 19 K10641, 19

CRediT authorship contribution statement
Yoshihiro Fuji: Conceptualization, Methodology, Data curation,
Writing – original draft, Visualization, Formal analysis, Software. Ryoto
Sakaniwa: Conceptualization, Supervision, Validation, Formal analysis,
Software, Writing – review & editing. Kokoro Shirai: Conceptualiza­
tion, Supervision, Validation, Formal analysis, Software, Writing – re­view & editing. Tami Saito: Conceptualization, Validation, Formal
6

Y. Fuji et al.

Preventive Medicine Reports 26 (2022) 101741

K11657, 19 K19818, 19 K19455, 19 K24060, 19 K20909, 20H00557) from
JSPS (Japan Society for the Promotion of Science); Health Labour Sciences
Research Grants (h26-Choju-Ippan-006, h27-Ninchisyou-Ippan-001, h28Choju-Ippan-002, h28-Ninchisyou-Ippan-002, h29-Chikyukibo-Ippan-001,
h30-Jyunkankinado-Ippan-004, 18H04071, 19FA1012, 19FA2001) from
the Ministry of Health, Labour and Welfare, Japan; the Research andDevelopment Grants for Longevity Science from Japan Agency for Medical
Research and development (AMED) (JP17dk0110027, JP18dk0110027,
JP18ls0110002, JP18le0110009, JP20dk0110034, JP20dk0110037,
21lk0310073h0002), the Research Funding for Longevity Sciences from
National Center for Geriatrics and Gerontology (20-19, 21-20, 24-17, 2423, 29-42, 30-30,30-22); Open Innovation Platform with Enterprises,
Research Institute and Academia (OPERA, JPMJOP1831) from the Japan
Science and Technology (JST); a grant from the Japan Foundation For
Aging And Health (J09KF00804), a grant from Innovative Research Pro­
gram on Suicide Countermeasures (1-4), a grant from Sasakawa Sports
Foundation, a grant from Japan Health Promotion & Fitness Foundation, a
grant from Chiba Foundation for Health Promotion & Disease Prevention,
the 8020 Research Grant for fiscal 2019 from the 8020 Promotion Foun­dation (adopted number: 19-2-06), a grant form Niimi University(1915010), grants from Meiji Yasuda Life Foundation of Health and Wel­fare, Osaka University Center of Medical Data Science Advanced Clinical
Epidemiology Investigator’s Research, and the OU-UCL Joint-Lab ResearchCenter in Osaka University. The views and opinions expressed in thisarticle are those of the authors and do not necessarily reflect the official
policy or position of the respective funding organizations.

older adults: Propensity score matching and instrumental variable analyses, JAGES
Taketoyo study. J. Epidemiol. Community Health 69 (9), 905–910. https://doi.org/
10.1136/jech-2014-205345.
Kanamori, S., Kai, Y., Aida, J., et al., 2014. Social participation and the prevention offunctional disability in older Japanese: The JAGES cohort study. PLoS One 9 (6),e99638. https://doi.org/10.1371/journal.pone.0099638.
Kobayashi, T., Tani, Y., Kino, S., et al., 2021. Prospective Study of Engagement in Leisure
Activities and All-Cause Mortality Among Older Japanese Adults. J. Epidemiol.
https://doi.org/10.2188/jea.JE20200427.
Komatsu, M., Obayashi, K., Tomioka, K., et al., 2019. The interaction effect between
physical and cultural leisure activities on the subsequent decline of instrumental
ADL: The Fujiwara-kyo study. Environ. Health Prev. Med. 24 (1) https://doi.org/
10.1186/s12199-019-0826-4.
Kondo, K., 2016. Progress in aging epidemiology in Japan: The JAGES project.
J. Epidemiol. 26 (7), 331–336. https://doi.org/10.2188/jea.JE20160093.
Kondo, K., Rosenberg, M., 2018. Advancing universal health coverage throughknowledge translation for healthy ageing. https://apps.who.int/iris/handle/10665/
279010 (accessed 9.1.2021).
Koyano, W., Shibata, H., Nakazato, K., et al., 1991. Measurement of competence:
reliability and validity of the TMIG Index of Competence. Arch. Gerontol. Geriatr.
https://doi.org/10.1016/0167-4943(91)90053-S.
Ling, L., Tsuji, T., Nagamine, Y., et al., 2020. Types and number of hobbies and incidence
of dementia among older adults: A six-year longitudinal study from the Japan
Gerontological Evaluation Study (JAGES). Nihon. Koshu Eisei Zasshi. 67, 800–810(in Japanese). https://doi.org/10.11236/jph.67.11_800.
Matsunaga, T., Naito, M., Wakai, K., et al., 2017. Leisure-time physical activity and riskof disability incidence: A 12-year prospective cohort study among young elderly of
the same age at baseline. J. Epidemiol. 27 (11), 538–545. https://doi.org/10.1016/j.
je.2016.11.004.
Ministry of Health, Labor and Welfare., 2013. Physical activity criteria to promote health2013. [PDF on the Internet]. http://www.mhlw.go.jp/stf/houdou/2r9852000002
xple-att/2r9852000002xpqt.pdf (in Japanese) (accessed 9.1.2021).
Ministry of Health, Labour and Welfare. Long-Term Care Insurance System of Japan.
http://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-elderly/dl/ltcisj_
e.pdf (accessed 9.1.2021).
Ministry of Health, Labor and Welfare. Promotion of exercise measures. https://www.
mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/kenkou/undou/index.html(accessed 9.1.2021).
Ministry of Health, Labour and Welfare. Long term care insurance business status report(annual report) Ministry of Health, Labour and Welfare. https://www.mhlw.go.jp/
topics/kaigo/osirase/jigyo/18/index.html (accessed 9.1.2021).
Ministry of Health, Labour and Welfare. The future outlook for social security with aneye on 2040 Ministry of Health, Labour and Welfare. https://www.mhlw.go.jp/stf/
seisakunitsuite/bunya/0000207382.html (accessed 9.1.2021).
Sugita, A., Ling, L., Tsuji, T., et al., 2020. Cultural engagement and incidence of cognitive
impairment: A six-year longitudinal follow-up of the Japan Gerontological
Evaluation Study (JAGES). J. Epidemiol. https://doi.org/10.2188/jea.je20190337.
Tomioka, K., Kurumatani, N., Hosoi, H., 2017. Association Between Social Participationand 3-Year Change in Instrumental Activities of Daily Living in Community-Dwelling
Elderly Adults. J. Am. Geriatr. Soc. 65 (1), 107–113. https://doi.org/10.1111/
jgs.2017.65.issue-110.1111/jgs.14447.
Tsutsui, T., Muramatsu, N., 2005. Care-needs certification in the long-term careinsurance system of Japan. J. Am. Geriatr. Soc. Doi: 10.1111/j.15325415.2005.53175.x.
Tsutsui, T., Muramatsu, N., 2007. Japan’s universal long-term care system reform of
2005: Containing costs and realizing a vision. J. Am. Geriatr. Soc. 55, 1458–1463.
https://doi.org/10.1111/j.1532-5415.2007.01281.x.
Ukawa, S., Tamakoshi, A., Okada, Y., et al., 2020. Social participation patterns and theincidence of functional disability: The Japan Gerontological Evaluation Study.
Geriatr. Gerontol. Int. 20 (8), 765–772. https://doi.org/10.1111/ggi.v20.810.1111/
ggi.13966.
Verghese, J., Lipton, R.B., Katz, M.J., et al., 2003. Leisure Activities and the Risk of
Dementia in the Elderly. N. Engl. J. Med. 348 (25), 2508–2516. https://doi.org/
10.1056/NEJMoa022252.
Vos, T., Lim, S.S., Abbafati, C., et al., 2020. Global burden of 369 diseases and injuries in
204 countries and territories, 1990–2019: a systematic analysis for the Global
Burden of Disease Study 2019. Lancet 396 (10258), 1204–1222. https://doi.org/
10.1016/S0140-6736(20)30925-9.
WHO, 2008. Age-Friendly Primary Health Care Centres Toolkit. http://apps.who.int/
iris/bitstream/handle/10665/43860/9789241596480_eng.pdf;
jsessionid=F18E6E06FE0556DD5F99DCF14F16? sequence=1 (accessed 9.1.2021).
WHO, 2017. Global action plan on the public health response to dementia 2017–2025 htt
ps://www.who.int/mental_health/neurology/dementia/action_plan_2017_2025/
en/2017 (accessed 9.1.2021).
Xu, W., Wang, H.F., Wan, Y., et al., 2017. Leisure time physical activity and dementia
risk: A dose-response meta-analysis of prospective studies. BMJ Open 7 (10),e014706. https://doi.org/10.1136/bmjopen-2016-014706.
Yates, R., Muchisky, D., 1997. Successful aging. Gerontologist 37, 433–440. https://doi.
org/10.5054/tq.2010.215250.

Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.pmedr.2022.101741.
References
Aida, J., Kondo, K., Kawachi, I., et al., 2013. Does social capital affect the incidence offunctional disability in older Japanese? A prospective population-based cohort
study. J. Epidemiol. Community Health 67 (1), 42–47. https://doi.org/10.1136/
jech-2011-200307.
Ainsworth, B.E., Haskell, W.L., Herrmann, S.D., et al., 2011. Healthy Lifestyles ResearchCenter, College of Nursing & Health Innovation, Arizona State University: The
Compendium of Physical Activities Tracking Guide. https://sites.google.com/site/co
mpendiumofphysicalactivities/home (accessed 9.1.2021).
Ashida, T., Kondo, N., Kondo, K., 2016. Social participation and the onset of functional
disability by socioeconomic status and activity type: The JAGES cohort study. Prev.
Med. (Baltim) 89, 121–128. https://doi.org/10.1016/j.ypmed.2016.05.006.
Barengo, N.C., Antikainen, R., Borodulin, K., et al., 2017. Leisure-Time Physical Activity
Reduces Total and Cardiovascular Mortality and Cardiovascular Disease Incidence inOlder Adults. J. Am. Geriatr. Soc. 65 (3), 504–510. https://doi.org/10.1111/
jgs.14694.
Beeri, M.S., Leurgans, S.E., Bennett, D.A., et al., 2021. Diverse Motor Performances Are
Related to Incident Cognitive Impairment in Community-Dwelling Older Adults.
Front. Aging Neurosci. 13 https://doi.org/10.3389/fnagi.2021.71713.
Chen, Y.M., Chiang, T.L., Chen, D.R., et al., 2016. Trajectories of Older Adults’ LeisureTime Activity and Functional Disability: a 12-Year Follow-Up. Int. J. Behav. Med. 23(6), 697–706. https://doi.org/10.1007/s12529-016-9554-y.
Corbett, D.B., Rejeski, W.J., Tudor-Locke, C., et al., 2018. Social Participation Modifies
the Effect of a Structured Physical Activity Program on Major Mobility Disability
among Older Adults: Results from the LIFE Study. Journals Gerontol. - Ser. B
Psychol. Sci. Soc. Sci. 73, 1501–1513. Doi: 10.1093/geronb/gbx051.
Doi, T., Verghese, J., Makizako, H., et al., 2017. Effects of Cognitive Leisure Activity on
Cognition in Mild Cognitive Impairment: Results of a Randomized Controlled Trial.
J. Am. Med. Dir. Assoc. 18 (8), 686–691. https://doi.org/10.1016/j.
jamda.2017.02.013.
eurostat Statistics Explained. Functional and activity limitations statistics. https://ec.
europa.eu/eurostat/statistics-explained/index.php/Functional_and_activity_
limitations_statistics#Self-reported_long-standing_limitations_ due_to_health_problems. (accessed 9.1.2021).
Hikichi, H., Kondo, N., Kondo, K., et al., 2015. Effect of a community intervention
programme promoting social interactions on functional disability prevention for7