The Relationship between Frailty and TCM Constitution in Elderly Individuals Living in a Community

Japan's population aged 65 and over accounts for 29.1% of the total population, the highest aging rate in the world [1]. The proportion of the elderly who are certified as requiring long-term care (support) has reached 19.1% (18.4% in March 2020), with men and women having 8.73 years and 12.07 years of long-term care required before they reach the end of their life span, respectively [2]. In 2020, the total cost of Japan's long-term care prevention insurance benefits amounted to 11.0542 trillion yen, highlighting the increasing economic burden of medical and caregiving expenses [3]. 

Under these circumstances, it is considered important to prevent the transition to a state requiring long-term care, as well as to prevent the deterioration of the state requiring long-term care. In Japan, Regional Long-Term Care Prevention Centers have been established so that elderly people can live well without the need for nursing care. In addition, “care prevention/frail prevention promoters” have been assigned to promote the expansion of care prevention activities such as community recreational areas and the strengthening of functions from the perspective of preventing frailty. 

People progress from a healthy state to pre-frailty, then frailty, and eventually to a state requiring long-term care. Frailty is characterized by its reversibility, allowing individuals to return to a healthy state through intervention, as well as its multifaceted nature, encompassing physical, mental, psychological, and social aspects [4]. Frailty is characterized by its reversibility, allowing individuals to return to a healthy state through intervention, as well as its multifaceted nature, encompassing physical, mental, psychological, and social aspects [5]. For prevention, it is important to address appropriate improvements from three aspects: nutrition, physical activity, and social participation. 

In TCM, the mental and physical states of human beings are considered to change continuously between health, pre-symptomatic state (between health and disease), and disease. The Nine Classifications of Constitution, based on TCM constitutional medicine, are attracting attention for treating pre-symptoms and curing pre-symptoms [6]. It is important to detect minor abnormalities in oneself and to cure the illness or to cure the unwellness, and there are five major types of curing the unwellness: curing eating and drinking, curing mental health, improving lifestyle, curing through exercise, and practicing self-care of acupuncture points [7]. From the viewpoint of this constitutional regimen, it is thought that the improvement of the constitution has more influence on the prevention and improvement of frailty than the improvement of the constitution. Therefore, we conducted a survey to clarify the relationship between frailty and TCM constitution.

The purpose of this study was to clarify the relationship between frailty and the chum physician's constitution in elderly people living in a community in Japan. 

• Research Methods 

Research Subjects and Duration: Three hundred and fifty elderly persons aged 65 years or older living in a community in S ward, K city, Japan. A cross-sectional survey was conducted using a self-administered, anonymous questionnaire. This study was approved by the Research Ethics Review Committee of Kyoto Koka Women's University (Approval No. 22MM03) and was conducted until November 2023. 

• Survey Contents 

Basic Attributes of the Elderly: Age, Gender, Education

Frailty Checklist: Although there is no standardized method for evaluating frailty, the method used in this study is the Basic Checklist (KCL), which includes physical, psycho-psychological, and social aspects of frailty and has been included in the manual for long-term care prevention since 2006. The basic checklist consists of 25 questions, and scores of 0-3 indicate healthy, 4-7 indicate pre-frailty, and 8 or more indicate frailty. 

Japanese version of the Questionnaire on Chinese Medicine Constitution (CCMQ-J): Criteria for determining TCM constitution (Chinese Society of Traditional Chinese Medicine 2009) (Table 1).

Table 1: Formula for calculating the Chugai constitution = [(total score of items - number of items)/number of items x 4] x 100.

(* Items 2, 7, 8, 9, 22, and 53 are inverted items when calculating the number of peace pledges.)

In this study, in order to analyze the results statistically, the constitution with a tendency to οο was also judged as οο constitution.

Those with a score of < 60 for the Peace constitution and < 30 for the Unwellness constitution are judged as not having one of the 9 types of TCM constitutions.

• Methods of analysis 

Data were analyzed by univariate and multivariate analysis. IBM SPSS Statistics 28 for Japanese was used for the analysis. 

• Research Results 

A total of 350 survey forms were distributed, of which 295 were collected. Additionally, due to incomplete entries on some forms, the total number of data points varies during analysis. 

• Basic Attributes of Research Collaborators 

In table 2, There were more female respondents than male respondents. Regarding the highest level of education, about half of the women were high school graduates, while the majority of men had a university degree or higher.

Table 2: Descriptive Statistics of Basic Attributes by Gender of Study Collaborators (N=295).

• The TCM constitution of research participants 

In table 3, Percentage of TCM constitution is 52.4% for balanced constitution > 44% for biased constitution. The proportions of biased constitutions in TCM were as follows: Phlegm-Damp Constitution 17.8% > Yang Deficiency Constitution 17.5% > Blood Stasis Constitution 14.9% > Yin Deficiency Constitution 13.1% > Qi Deficiency Constitution 12.7% > Special Diathesis Constitution 12.4% > Qi Stagnation Constitution 6.2% > Damp-Heat Constitution 2.9%.

 Table 3: Frequency distribution of the study collaborators' TCM constitution.

• The frailty of research participants

In table 4, The distribution was as follows: healthy 46.3% > pre-frailty > 35.2% > frailty 18.5%.

 Table 4: Frequency Distribution of Frailty Status Among Research Participants.

• Distribution of TCM Constitutions Among Frail Individuals 

In table 5, The proportion of TCM constitutions among frail individuals was as follows: Biased Constitution 72.3% > Balanced Constitution 21.3%. The distribution was as follows: Qi deficiency constitution = Yang deficiency constitution = Phlegm-damp constitution 38.3% > Special endowment constitution 34% > Yin deficiency constitution = Blood stasis constitution 29.8% > Qi stagnation constitution 19.1% > Damp-heat constitution 4.3%. The numbers of individuals with Damp-heat constitution and Qi stagnation constitution were relatively low, showing a similar trend to that of the overall study population.

 Table 5: Frequency Distribution of TCM Constitutions among Frail Individuals.

• The relationship between frailty and TCM disposition

In table 6, Significant negative correlations were found between total frailty score (r=-.509**), social frailty score (r=-.202**), mental/psychological frailty score (r=-.472**), physical frailty score (r=-.436**) and peace quality score.

Significant positive correlations were observed between the biased constitution score and the total frailty score, mental/psychological frailty score, and physical frailty score.

Table 6: Spearman correlation coefficients between frailty item scores and TCM Constitution scores.

*p<0.05**p<0.01

Among the elderly who responded to the survey, more women than men were likely to participate in community activity classes. The final education level of males was higher than that of females. 

TCM constitution is determined by a combination of innate genetic factors, acquired social and environmental influences, lifestyle, as well as geographical and climatic elements. In addition, the TCM constitution can change with age, diet, environment, disease, drugs, and other factors. In TCM, the treatment of illness is closely related to the patient's constitution. Even with the same causative factors, the manifestation of the disease varies depending on the constitution, and treatment plans differ for each patient. Between 2009 and 2018, a total of 1,441 studies on TCM constitution were conducted in China. Previous research on TCM constitution has shown a strong correlation with lifestyle-related diseases such as malignant tumors, obesity, hypertension, and diabetes [8-13]. Improving TCM constitution has been reported to positively impact the control of hypertension and high blood sugar, enhance heart and lung function, adjust the sleep condition of insomnia patients, and contribute to the treatment and improvement of depression [14-18]. 

There are few reports on the relationship between frailty and TCM constitution. Within mental/psychological frailty, there is a concept known as cognitive frailty, which refers to a group of frail individuals with cognitive decline. People with dementia are more likely to become frail and are at a higher risk of falls and fractures. Phlegm-damp constitution, yin deficiency constitution, and yang deficiency constitution are more likely to develop cognitive frailty [19]. Phlegm-damp constitution is a risk factor for obesity [11], and a higher proportion of MCI patient’s exhibit phlegm-damp constitution [20]. Additionally, Qi stagnation constitution is significantly associated with an increased risk of MCI onset. In Japan, there have been no reports examining the relationship between TCM constitution and frailty, and further research accumulation is necessary in the future.

Due to the small sample size in the statistical analysis, it is possible that the results may be biased. As this study was a cross-sectional study conducted in a specific region, the research participants cannot be considered representative of the entire population of Japan. It was a cross-sectional study. Conducting longitudinal studies or intervention studies to examine the relationship between frailty and TCM constitution could lead to the verification of the effectiveness of frailty prevention and the discovery of new valuable insights.

Frailty was found to have a negative correlation with the Peaceful Constitution. The Peaceful Constitution is characterized by a good balance of yin and yang in TCM, suggesting that maintaining a constitution with balanced yin and yang is important. On the other hand, a positive correlation with biased constitution was revealed. In other words, it was suggested that elderly individuals with a biased constitution are more likely to develop frailty.

We would like to express our sincere gratitude to the members of the Center for Community Care and Prevention, S ward, K city, Japan, and our research collaborators for their great cooperation in this study. I would like to express my sincere gratitude to all the professors who gave me detailed guidance in planning, analyzing, and writing the paper for this study.

There are no conflicts of interest to disclose in this study.

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