2.2. Measurements of Functional Decline and Frailty Status

The KCL is a questionnaire developed in Japan to identify vulnerable older adults who are at a high risk of becoming dependent. The KCL has been used to predict frailty and disability. It is a self-administered questionnaire that consists of 25 yes/no questions in seven domains, namely the instrumental activities of daily living (IADL) decline, physical decline, malnutrition, oral dysfunction, being homebound, cognitive decline, and depressive mood, as seen in Table S1 [15,16]. Difficulty answering any kind of question was counted as a point on the KCL. A higher score in each domain of the checklist means a higher risk of requiring support or care in a given domain. The assessment of functional decline in each domain is defined as follows: a score of three or more out of the five items in the physical domain (questions number 6–10) indicates a physical decline. A full score of both of the items in the nutritional status domain (questions number 11 and 12) and a score of two or more out of the three items in the oral function domain (questions number 13–15) indicate malnutrition and oral dysfunction, respectively. Homebound is defined by the answer of ‘no’ to question number 16 in the socialization domain (questions number 16 and 17). In addition, a score of one or more out of the three items in the cognitive function domain (questions number 18–20) and a score of two or more out of the five items in the mood domain (questions number 21–25) suggest cognitive decline and depressive mood, respectively [17]. We also defined a score of 10 or more out of the 20 items (questions number 1–20), including the IADL domain (question numbers 1–5), as IADL decline. The total KCL (t-KCL) score is useful for the screening of not only physical frailty but also mental, psychological, and social frailty in older adults as well as for predicting support/care-need certification [18,19]. We considered t-KCL scores of 0–3, 4–7, and 8+ to represent robust, pre-frail, and frail, respectively [20].

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