Overlap of Physical, Cognitive, and Social Frailty Affects Ikigai in Community-Dwelling Japanese Older Adults
Round 1
Reviewer 1 Report
I would like to thank the authors for a very interesting article. The authors of this article have exhaustively searched the scientific literature, carrying out a complete introduction that correctly puts the reader in the background on the developed topic. Also, in my opinion, the English language is correct, clear and understandable throughout the manuscript.
Although it is necessary to make a series of modifications so that it can be accepted.
In general, this section is messy. Please, the authors should order the information in different sections:
Materials and Methods
2.1. Study design.
In this section you must describe the type of study, dates of the study, Ethics Committee.
2.2. Participants
The characteristics of the participants, inclusion and exclusion criteria, and a flowchart of the participants.
2.3. Sample Size Calculation
The work must include the calculation of the sample with reference to the literature and with sufficient detail to allow replication.
2.4. Outcomes
The variables and measurement instruments used to measure said variables.
2.5. Data analysis
All the procedure used for data analysis.
The authors of this article have explained the results in detail, providing tables relevant to what is explained in the text and good quality figures. However, in all footnotes to the table, you must specify the meaning of the acronyms that appear in the table.
Lastly, the references section complies with the standards established by the journal and is homogeneous
Author Response
Response to Reviewer 1 Comments
Kobe International University Faculty of Rehabilitation Department of Physical Therapy
Souma Tsuzishita
Thank you for pointing this out. I have included the corrected information below.
Point 1:
2.1. Study design.
In this section you must describe the type of study, dates of the study, Ethics Committee.
Response 1:
Thank you for pointing this out.
As you indicated, we have made the correction.
Point 2:
2.2. Participants
The characteristics of the participants, inclusion and exclusion criteria, and a flowchart of the participants.
Response 2:
Thank you for pointing this out.
As you indicated, we have made the correction.
Point 3:
2.3. Sample Size Calculation
The work must include the calculation of the sample with reference to the literature and with sufficient detail to allow replication.
Response 3:
Thank you for pointing this out.
As you indicated, we have made the correction.
The following text has been added
[Using G*Power 3.1 software (Heinrich Heine University, Düsseldorf, Germany), the sample size for frailty was calculated as power 80%, alpha error 0.05, and effect size 0.40 (large). The number of participants required for this study was found to be 66. To account for the possibility of participant attrition, 130 participants were recruited.]
Point 4:
2.4. Outcomes
The variables and measurement instruments used to measure said variables.
Response 4:
Thank you for pointing this out.
As you indicated, we have made the correction.
Point 5:
2.5. Data analysis
All the procedure used for data analysis.
Response 5:
Thank you for pointing this out.
As you indicated, we have made the correction.
Point 6:
The authors of this article have explained the results in detail, providing tables relevant to what is explained in the text and good quality figures. However, in all footnotes to the table, you must specify the meaning of the acronyms that appear in the table.
Response 6:
Thank you for pointing this out.
The meaning of abbreviations is added.
Point 7:
Lastly, the references section complies with the standards established by the journal and is homogeneous
Response 7:
Thank you for pointing this out.
As you indicated, we have made the correction.
Author Response File: 
Author Response.docx
Reviewer 2 Report
Congratulations on the job. I suggest minor changes for the improvement of the article. To facilitate the understanding of the article, I would include the value of each p in Table 2, 3 and 4. In the same way, I would add in the text the exact value of p. In Limitations should include that they use a subjective method to measure cognitive frailty and that the pandemic could influence the ikigai of the participants. It would also be convenient to specify whether or not the participants were infected with COVID-19, since it can influence the results.Author Response
Response to Reviewer 2 Comments
Kobe International University Faculty of Rehabilitation Department of Physical Therapy
Souma Tsuzishita
Thank you for pointing this out. I have included the corrected information below.
Point 1:
Congratulations on the job. I suggest minor changes for the improvement of the article. To facilitate the understanding of the article, I would include the value of each p in Table 2, 3 and 4. In the same way, I would add in the text the exact value of p.
Response 1:
Thank you for pointing this out.
The p-values are appended.
Point 2:
In Limitations should include that they use a subjective method to measure cognitive frailty and that the pandemic could influence the ikigai of the participants.
Response 2:
Thank you for pointing this out.
The following statement was added regarding the limitations of the study.
[Limitations and issues of this study include the fact that the study was conducted from July to November 2021, and the COVID-19 pandemic was expected to have a nega-tive impact on frailty, risk of falling, ADL impairment, and Ikigai, resulting in a low over-all figure. Furthermore, since the sample size was small in this study, future studies will need to increase the sample size and consider which combination of each combination affects adverse events. Finally, cognitive frailty was defined as a combination of subjective cognitive decline and physical prefrailty, based on previous studies. This was due to the predicted lower prevalence when assessed by objective cognitive decline and also because of the burden on the study subjects. However, we believe that future studies will be able to validate more reliably by assessing objective cognitive decline.]
Point 3:
It would also be convenient to specify whether or not the participants were infected with COVID-19, since it can influence the results.
Response 3:
Thank you for pointing this out.
The presence of COVID-19 infection was added to the exclusion criteria.
Author Response File: Author Response.docx
Reviewer 3 Report
The authors aims to determine the association of physical, cognitive, and social frailty with Ikigai among older adults. The paper is well-written, however there are some concerns that need to be addressed by the authors, especially the method use to detect participants with cognitive frailty.
1. Cognitive impairment was assessed subjectively by the presence or absence of subjective cognitive decline based on the single question from GDS-15. There might be biased and inaccurate in confirming those who have cognitive problems. Additional cognitive test such as MMSE or MoCA could be used for this purpose.
2. I would suggest to divide the methodology part into different sub-topics instead of putting everything together under one topic.
3. "The prevalence of cognitive frailty was 51 (44.0%), and robust was 65 (56.0%).". Is participants with subjective cognitive complaints and physical prefrailty consider as having cognitive frailty?
4. In the results part, "For variables showing significant associations, multiple comparisons showed that physical, cognitive, and social frailty had significantly negative effects compared to being robust". What are the negative effects referring to? Ikigai, risk of falls or both?
5. "For variables showing significant associations, multiple comparisons showed a significant negative effect of two or more frailty category overlaps compared to being robust". Similar to the above comments, what are the negative effects?
6. The figure legend of Fig.1 is confusing. Please indicate clearly the comparison are between which groups.
7. Is this study a cross-sectional study? is yes please indicate it in the methodology part.
8. In the discussion part, the author mentioned that there is discrepancies in the prevalence of cognitive frailty between the current findings and the previous findings due to the use of single question to determine cognitive impairment subjectively in order to detect a larger number of participants for cognitive frailty. I don't think this is a proper justification for doing so and this may void the validity of the findings, especially findings with regards to cognitive frailty.
9. The authors should better describe the relationship between ikigai and physical, cognitive and social frailty. How Ikigai affect different type of frailty or how frailty affects ikigai?
10. If this is a cross-sectional study, please include this as one of the limitations of the study since the causal relationship between ikigai and different subtype of frailty was not be able to access in this study.
11. the last paragraph of the discussion is similar to the conclusion part. Please remove it to avoid repetition.
Author Response
Response to Reviewer 3 Comments
Kobe International University Faculty of Rehabilitation Department of Physical Therapy
Souma Tsuzishita
Thank you for pointing this out. I have included the corrected information below.
Point 1:
Cognitive impairment was assessed subjectively by the presence or absence of subjective cognitive decline based on the single question from GDS-15. There might be biased and inaccurate in confirming those who have cognitive problems. Additional cognitive test such as MMSE or MoCA could be used for this purpose.
Response 1:
Thank you for pointing this out.
Assessments of cognitive frailty are, even at this time, varied. It has also been noted that the prevalence of objective cognitive decline combined with prefrail is very low. Therefore, based on previous studies, we defined the combination of subjective cognitive decline and prefrail as cognitive frailty in this study. This assessment also takes into account the subject's burden.
The following text has been added
[Cognitive frailty was defined as a combination of subjective cognitive decline and physical prefrailty, based on previous research [16]. As methods for assessing cognitive frailty, physical frailty and reduced gait speed are used to assess physical function decline, and as for cognitive decline, as with MCI, some studies use objective cognitive decline, some use subjective cognitive decline, and some use Clinical dementia rating (CDR) 0.5, and others have reported variation among studies [17]. The prevalence of cognitive frailty has also been reported to vary by population, ranging from 1.0 to 39.7% [17]. The reason for using the combination of subjective cognitive decline and physical prefrailty as the as-sessment of cognitive frailty in this study was that using the combination of objective cog-nitive decline and physical frailty could have resulted in a much lower prevalence rate. In a previous study, the prevalence of cognitive frailty, defined by physical frailty and objec-tive cognitive decline, was 1.2% [18, 19]. Another advantage is that the assessment of sub-jective cognitive function is less burdensome for the subject, who is an elderly person. Subjective cognitive decline was defined as those who answered "Yes" to the Geriatric De-pression Scale 15 (GDS15) question " Do you feel you have more problems with memory than most?" [16].]
Point 2:
I would suggest to divide the methodology part into different sub-topics instead of putting everything together under one topic.
Response 2:
Thank you for pointing this out.
As you indicated, we have made the correction.
Point 3:
"The prevalence of cognitive frailty was 51 (44.0%), and robust was 65 (56.0%).". Is participants with subjective cognitive complaints and physical prefrailty consider as having cognitive frailty?
Response 3:
Thank you for pointing this out.
Once again, the prevalence of cognitive frailty in previous studies has ranged from 1% to 40%. Therefore, the prevalence rate in this study also seems to have some validity. The definition of cognitive frailty in this study is the combination of subjective cognitive decline and prefrailty.
The following text has been added
[the prevalence of cognitive frailty has also been reported to vary by population, ranging from 1.0 to 39.7% [17], ]
Point 4:
In the results part, "For variables showing significant associations, multiple comparisons showed that physical, cognitive, and social frailty had significantly negative effects compared to being robust". What are the negative effects referring to? Ikigai, risk of falls or both?
Response 4:
Thank you for pointing this out.
The following text has been added
[Multiple comparisons of variables that showed significant associations indicated that physical frailty, cognitive frailty, and social frailty had a significant negative impact on fall risk and Ikigai compared to being robust.]
Point 5:
"For variables showing significant associations, multiple comparisons showed a significant negative effect of two or more frailty category overlaps compared to being robust". Similar to the above comments, what are the negative effects?
Response 5:
Thank you for pointing this out.
The following text has been added
[Multiple comparisons of variables that showed significant associations indicated that physical frailty, cognitive frailty, and social frailty had a significant negative impact on Ikigai compared to being robust (shown in Figure 2).]
Point 6:
The figure legend of Fig.1 is confusing. Please indicate clearly the comparison are between which groups.
Response 6:
Thank you for pointing this out.
As you indicated, we have made the correction.
Point 7:
Is this study a cross-sectional study? is yes please indicate it in the methodology part.
Response 7:
Thank you for pointing this out.
As you indicated, we have made the correction.
Point 8:
In the discussion part, the author mentioned that there is discrepancies in the prevalence of cognitive frailty between the current findings and the previous findings due to the use of single question to determine cognitive impairment subjectively in order to detect a larger number of participants for cognitive frailty. I don't think this is a proper justification for doing so and this may void the validity of the findings, especially findings with regards to cognitive frailty.
Response 8:
Thank you for pointing this out.
Assessments of cognitive frailty are, even at this time, varied. It has also been noted that the prevalence of objective cognitive decline combined with prefrail is very low. Therefore, based on previous studies, we defined the combination of subjective cognitive decline and prefrail as cognitive frailty in this study. This assessment also takes into account the subject's burden. Once again, the prevalence of cognitive frailty in previous studies has ranged from 1% to 40%. Therefore, the prevalence rate in this study also seems to have some validity. The definition of cognitive frailty in this study is the combination of subjective cognitive decline and prefrailty.
Point 9:
The authors should better describe the relationship between ikigai and physical, cognitive and social frailty. How Ikigai affect different type of frailty or how frailty affects ikigai?
Response 9:
Thank you for pointing this out.
The following text has been added
[Another concept similar to Ikigai is "purpose in life". The elderly with a high sense of purpose tend to have goals and aspirations for the future and find meaning in their daily activities, according to reports [32]. It has also been suggested that people with a greater sense of purpose are more likely to engage in activities such as exercise and social partic-ipation, which may prevent dementia risk [33]. In other words, in this study, those who have Ikigai have goals for the future and find meaning in their daily activities, which are more likely to induce activities such as exercise and social participation, and these factors may account for the low percentage of those with physical, cognitive and social frailty.]
Point 10:
If this is a cross-sectional study, please include this as one of the limitations of the study since the causal relationship between ikigai and different subtype of frailty was not be able to access in this study.
Response 10:
Thank you for pointing this out.
The following text has been added
[Limitations and issues of this study include the fact that the study was conducted from July to November 2021, and the COVID-19 pandemic was expected to have a nega-tive impact on frailty, risk of falling, ADL impairment, and Ikigai, resulting in a low over-all figure. Furthermore, since the sample size was small in this study, future studies will need to increase the sample size and consider which combination of each combination affects adverse events. Also, cognitive frailty was defined as a combination of subjective cognitive decline and physical prefrailty, based on previous studies. This was due to the predicted lower prevalence when assessed by objective cognitive decline and also because of the burden on the study subjects. However, we believe that future studies will be able to validate more reliably by assessing objective cognitive decline. Finally, there is no access to the causal relationship between the different subtypes of frailty and Ikigai.]
Point 11:
the last paragraph of the discussion is similar to the conclusion part. Please remove it to avoid repetition.
Response 11:
Thank you for pointing this out.
As you indicated, we have made the correction.
Author Response File: Author Response.docx
Round 2
Reviewer 1 Report
The authors have made the proposed corrections. The manuscript can be accepted.
Author Response
Thank you for confirming. We have corrected it once again.
Author Response File: Author Response.docx
Reviewer 3 Report
The authors have amended the manuscript based on the previous comments.
Author Response
Thank you for confirming. We have corrected it once again.
Author Response File: Author Response.docx
