J Nutr Health Aging
CLIMBING STAIRS, HANDRAIL USE, AND SURVIVAL J. STESSMAN1,2, Y. ROTTENBERG1,3, J.M. JACOBS1,2 1. Institute of Aging Research; 2. Department of Geriatrics and Rehabilitation; 3. Department of Oncology Hadassah-Hebrew University Medical Center, Mount Scopus, and The Hebrew University-Hadassah Medical School, Jerusalem, Israel. Corresponding author: Dr. Jeremy M Jacobs, Institute of Aging Research, Department of Geriatrics and Rehabilitation, Hadassah Hebrew-University Medical Center, Mt. Scopus. P.O. Box 24035, Jerusalem 91240, Israel. E-mail:
[email protected]; Tel: 972-2-5844474, Fax: 972-2-5810918; Alternative Corresponding Author/Reprint requests: Professor Jochanan Stessman, Institute of Aging Research, Department of Geriatrics and Rehabilitation, Hadassah Hebrew-University Medical Center, Mt. Scopus. P.O. Box 24035, Jerusalem 91240, Israel. E-mail:
[email protected], Tel: 972-2-5844474, Fax: 972-2-5810918
Abstract: Background: Negotiating stairs is identified as a challenging task by older people, and using a handrail to climb stairs is a compensatory gait strategy to overcome mobility difficulties. We examine the association between handrail use to climb stairs at increasing ages, and long term survival. Methods: Data were collected by the Jerusalem Longitudinal Study, which is a prospective study of a representative sample from the 1920-1921 birth-cohort living in West Jerusalem. Comprehensive assessment at home in 1990, 1998, and 2005, at ages 70 (n=446), 78 (n=897), and 85 (n=1041) included direct questioning concerning handrail use for climbing stairs. Mortality data were collected from age 70-90. Results: The frequency of handrail use to climb stairs at ages 70, 78, 85 years was 23.1% (n=103/446), 41.0% (n=368/897), and 86.7% (n=903/1041) respectively. Handrail use was associated throughout follow-up with a consistent pattern of negative demographic, functional and medical parameters. Between ages 70-78, 70-90, 78-85, 78-90, and 85-90, survival was significantly lower among subjects using a handrail, with unadjusted mortality Hazard Ratios of HR 1.57 (95%CI, 1.01-2.42), HR 1.65 (95%CI, 1.27-2.14), HR 1.78 (95%CI, 1.41-2.25), HR 1.71 (95%CI, 1.41-2.06), and HR 1.53 (95%CI, 1.012.33) respectively. HR’s remained significant at all ages after adjusting for sociodemographic factors (gender, education, marital, and financial status), and common medical conditions (ischemic heart disease, hypertension, diabetes, chronic pain), as well as between ages 78-85 and 78-90 after adjusting for functional covariables (selfrated health, physical activity, depression, BMI and ADL difficulties). Conclusion: Using a handrail to climb stairs is increasingly common with rising age, was associated with a negative profile of health parameters and is associated with subsequent mortality. Key words: Stair negotiation, handrail use, mortality, survival, mobility, longitudinal follow-up.
Introduction
Methods
Negotiating stairs is an important component of basic function, and a prominent performance measure of mobility (1, 2). Often identified by older people as being a challenging task, the use of a handrail to climb stairs may serve as an early marker of poor health, difficulty and declining function and a compensatory gait strategy (3). The ability to negotiate stairs is most likely determined by a wide spectrum of factors, including cognitive, perceptual, psychological, physical, sensorimotor as well as biomechanical parameters (1-5). There exists a consensus that the identification of early markers of subsequent disability is clinically important, and preclinical mobility difficulties have been shown to predict subsequent incident disability (6). Although research has described parameters which may contribute to stair negotiation performance (7), very little longitudinal data exists concerning the usefulness of stair climbing ability to predict subsequent function (8, 9). To the best of the authors’ knowledge, the long-term survival associated with using a handrail during stair climbing, has not been described. The aim of the current study was to describe the prevalence of handrail use and the clinical profile associated with the need to use a handrail to climb stairs at ages 70, 78 and 85, and to determine if handrail use at different ages was associated with long term survival.
Basic Methodology and Sampling Study Population The study population is part of the ongoing Jerusalem Longitudinal Study (1990-2015), which is a prospective observational longitudinal study (10-13). The sample frame throughout the duration of the research has been the birth cohort born in 1920/21, which was resident in Western Jerusalem during the study period. Subjects were randomly chosen from the national electoral register, and were aged 70–71 at baseline in 1990–91 (n=456). At subsequent study phases, follow-up was performed at age 77–78 (1997/8, n=923), and 85–86 (2005/6, n=1115). The study sample has been proven to be representative, as shown by similar morbidity, mortality and hospitalization rates when comparing between study subjects, those who declined to enroll in the study, and those subjects from the birth cohort not approached (10-12). In order to counteract the effects of mortality upon sample size, the sample frame was augmented at ages 78 and 85, with additional randomly chosen subjects from the same birth cohort. No significant differences in frequency of handrail use were found between newly recruited subjects and those recruited at prior stages of the study. In situations where subjects with cognitive decline were unable to answer specific questions, information was collected by proxy from guardians present at the time of interview. Each participant, or legal guardian, provided informed consent, and the Hadassah-
Received October 12, 2015 Accepted for publication December 3, 2015
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J Nutr Health Aging
STAIRS, HANDRAIL, AND SURVIVAL Hebrew University Medical Center Institutional Review Board approved the study.
years of study); financial status (“do you have difficulty getting through the month?”); smoking (defined as ever vs. never smoked); body mass index (BMI kg/m2); self-rated health (good versus poor); fatigue (self assessed); depression was identified using the Brief Symptom Inventory, with subjects asked to grade from 0 (none) to 4 (greatly) how much they had suffered in the previous month from: a) loneliness; b) lack of interest; c) thoughts of ending one’s life; d) bad mood; e) hopelessness concerning the future; f) worthlessness.
Measurements and data collection Subjects were interviewed and examined in their homes by trained study personnel, according to a structured interview that lasted about an hour and a half. The following characteristics were examined: gender; marital status (married versus not married); education (low educational status defined as <12
Table 1 Clinical profile of subjects according to handrail use at ages 70, 78, and 85 Variable
Age 70 (N=446)
Age 78 (N=897)
Handrail Use %(n)
Yes
Handrail Use%(n)
No
Yes
No
Age 85 (N=1041)
Handrail Use %(n)
Yes
No
23.1%(103)
76.9%(343)
41.0%(368)
59.0%(529)
86.7%(903)
13.3%(138)
Female
61.2%(63)
39.4%(135)***
66.0%(243)
38.6%(204)***
58.1%(525)
29.7%(41)***
Low Educational level (<12 years)
65.0%(67)
46.9%(161)**
64.8%(201)
43.3%(219)***
55.0%(497)
46.4%(64)
35.6%(36)
49.1%(167)*
30.2%(98)
41.5%(195)**
Sociodemographic Marital status (married) Poor financial status Smoking (ever)
BMI ±SD (kg/M2) Functional
66.3%(67) 33.0%(33) 28.2±4.7
72.2%(244)
51.9%(191)
17.7%(60)**
29.8%(104)
26.8±3.7**
28.9±5.5
64.4%(340)** 10.2%(52)*** 26.8±3.8***
42.1%(367) 17.1%(149) 39.5%(356) 27.5±4.6
Poor-self rated health
52.9%(54)
20.2%(69)***
61.0%(224)
25.6%(135)***
35.6%(306)
Depression
24.1%(21)
12.7%(40)**
33.0%(67)
16.1%(69)***
36.6%(313)
Fatigue
Low Physical Activity Not reading daily
Poor sleep satisfaction Poor vision
47.6%(49)
23.9%(82)***
69.5%(246)
39.7%(206)***
73.5%(75)
36.5%(125)***
36.5%(114)
37.2%(38)
20.8%(71)**
33.3%(118)
17.9%(94)***
23.1%(74)**
47.4%(144)
33.2%(158)***
1.2%(3)***
10.6%(17)
2.0%(7)***
43.0%(34)
38.5%(124)
43.6%(112)
34.6%(162)*
40.2%(39)
17.3%(59)***
78.7%(59)
46.4%(112)***
BADL difficulty
41.2%(40)
6.6%(22)***
51.1%(179)
7.0%(36)***
Chronic Pain
70.9%(73)
56.8%(195)*
74.2%(273)
64.5%(341)***
Hypertension
46.6%(48)
36.4%(125)
60.4%(195)
IHD
30.1%(31)
24.5%(84) 3.7±4.0**
Poor hearing
Grip strength
BADL dependence Fall ≥1 in last year Medical
Diabetes mellitus Cancer
Medications number ±SD
39.8%(39) 12.8%(5)
14.4%(14) 36.9%(38)
17.6%(18) 5.8%(6) 5.1±4.1
22.4%(66)
9.2%(44)***
72.1%(119)
0.6%(2)***
22.8%(80)
25.4%(87)*
38.7%(141)
15.7%(54)
37.2%(73)***
1.6%(8)***
49.3%(68)*
25.8±3.2*** 10%(13)***
69.7%(605)
37.1%(49)***
31.8%(276)
5.3%(7)***
48.1%(338) 30.3%(271)
18.6%(24)*** 48.8%(62)
21.7%(30)*
48.3%(415)
32.3%(42)**
60.6%(542)
28.7%(39)***
46.6%(404)
19.7%(26)***
31.0%(280)
15.2%(21)**
66.2%(575) 21.3%(183) 32.9%(285)
68.2%(90)
11.6%(15)*
9.8%(13)***
26.8%(37)***
49.2%(242)**
74.2%(649)
59.1%(78)**
39.9%(129)
30.5%(150)**
37.6%(340)
26.1%(36)**
8.9±6.6
7.3±5.4**
12.8±6.9
9.0±6.2***
4.9%(16)
20.8%(109)***
9.1%(12)*
45.8%(411)
23.5%(76)
2.9%(10)
10.6%(49)***
55.3%(73)*
14.6%(72)** 6.7%(33)
20.3%(178) 9.0%(81)
13.6%(18) 3.6%(5)*
*p<0.05 **p<0.01 ***p<0.0001; The p values refer to comparison between those using a handrail to those not using a handrail at the same age (70, 78, and 85); Abbreviations: BMI –Body mass index; BADL-Basic activities of daily living; MMSE-Mini mental state examination; IHD- Ischemic heart disease; SD-Standard deviation
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THE JOURNAL OF NUTRITION, HEALTH & AGING© Table 2 Handrail use and Mortality Hazards Ratios Survival Rates (%)
Mortality Hazards Ratio (HR) for Handrail Use (95% confidence intervals)
With Handrail
Without handrail
Log Rank P-value
Unadjusted HR
Adjusted HR According to Model Social
Functional (1)
Functional (2)
Medical
Age70-78
71.80%
80.20%
0.0418
1.57 (1.01-2.42)
1.67 (1.06-2.65)
1.00 (0.59-1.71)
0.83 (0.46-1.50)
1.69 (1.08-2.63)
Age70-90
24.10%
43.30%
<0.0001
1.65 (1.27-2.14)
1.81 (1.37-2.41)
1.3 (0.95-1.79)
1.15 (0.81-1.62)
1.73 (1.32-2.26)
Age 78-85
59.90%
74.90%
<0.0001
1.78 (1.41-2.25)
1.85 (1.4-2.44)
1.66 (1.16-2.39)
1.59 (1.08-2.33)
1.75 (1.36-2.27)
Age 78-90
38.50%
57.90%
<0.0001
1.71 (1.41-2.06)
1.79 (1.44-2.24)
1.67 (1.27-2.19)
1.55 (1.16-2.09)
1.67 (1.36-2.05)
Age 85-90
74.4%
82.6%
0.045
1.53 (1.01-2.33)
1.82 (1.15-2.87)
1.11 (0.69-1.80)*
1.02 (0.63-1.66)**
1.43 (0.92-2.23)
Social Model covariates: Gender, education, marital status, financial status; Functional Model 1 covariates: self rated health, depression, physical activity, BMI; Functional Model 2 covariates: self rated health, depression, physical activity, BMI, difficulty in basic activities of daily living; Medical Model covariates: Ischemic heart disease, hypertension, diabetes mellitus, chronic pain; * At age 85, addition of cognitive impairment (MMSE≤24) to “functional” model 1 resulted in no significant change in magnitude of findings: Model 1 HR 1.11 (0.68-1.79); ** At age 85, addition of cognitive impairment (MMSE≤24) to “functional” model 2 resulted in no significant change in magnitude of findings: Model 2 HR 1.01 (0.62-1.65)
data were collected from the Ministry of Interior, which is automatically updated following death certification. The number of people aged >70 emigrating and dying outside of Israel is extremely low (<1%), and mortality data capture can be considered to be complete.
Depression was defined as a total score of ≥ 6/24 points (14); current level of physical activity was assessed according to the question “How often are you physically active?” and dichotomized to Not active (
Statistical analyses Descriptive statistics were performed, and results are described as means and standard deviations. Differences between means were calculated using t-tests or chi-square tests or one-way ANOVA. All P-values were two-tailed, and p < 0.05 was considered to be significant. Kaplan-Meier survival charts and log-rank values were determined. Logistic regression analyses were performed for cross sectional data (Table 3 Appendix), and Hazards Ratios were determined using Cox proportional hazards models. Models were constructed according to associated baseline characteristics and known mortality risk factors. The following covariates were included in a Social Model (Gender, education, marital status, financial status), a Functional Model 1 (self rated health, depression, physical activity, BMI), a Functional Model 2 (self rated health, depression, physical activity, BMI, difficulty in basic activities of daily living), and a Medical Model (Ischemic heart disease, hypertension, diabetes mellitus, chronic pain).The data storage and analysis was performed using SAS version 9.3 (SAS Institute, Inc., Cary, NC).
Handrail use Subjects were asked if they were able to climb stairs unassisted or required the use of a handrail. At age 70, 78 and 85 a total of 10, 26, and 74 subjects respectively, reported being unable to climb stairs at all due to mobility problems, and these subjects were excluded from the study. The final study sample thus comprised at ages 70, 78 and 85, a total of 446, 897, and 1041 subjects respectively.
Results The frequency of using a handrail to climb stairs doubled with each successive study phase, and was reported at ages 70, 78, 85 years to be 23.1% (n=103/446), 41.0% (n=368/897), and 86.7% (n=903/1041) respectively. The prevalence of handrail use according to baseline characteristics with increasing age is shown in Table 1. Female subjects were more likely to use a handrail than males throughout the entire study period of follow-up. Handrail use was associated throughout follow-up
Mortality Data Death was the primary outcome measure, and mortality 3
J Nutr Health Aging
STAIRS, HANDRAIL, AND SURVIVAL with a consistent pattern of negative demographic, functional and, to a lesser extent, medical parameters. In particular, the use of handrail to climb stairs was most pronounced in subjects with fatigue, lower than average grip strength, low levels of physical activity, poor self-rated health, poor sleep satisfaction, impaired vision, depression, cognitive impairment, as well as dependence and difficulty in performing basic activities of daily living. Logistic regression analyses were performed to further explore the predictors of handrail use at ages 70, 78, and 85. Cross-sectional data were examined in sociodemographic, functional and medical models, with results shown in Table 3 (Appendix). Whilst numerous factors at various ages were predictive of handrail use, the strongest significant predictors were female gender, poor financial status, poor self rated health, low physical activity level, difficulty in activities of daily living, BMI and number of medications.
“sociodemographic” factors (Social model: gender, education, marital status, and financial status), as well as common chronic medical conditions (Medical model : Ischemic heart disease, hypertension, diabetes mellitus, and chronic pain). Between the ages 78-85 and 78-90, the association of handrail use and mortality remained significant after adjusting for “functional” co variables (Functional model 1: which included self rated health, low level of physical activity, depression, BMI; and Functional model 2 which also included difficulty in ADL in addition to the above), however this association was not significant between ages 70-78. 70-90, and 85-90. Due to relatively low levels of cognitive impairment among the study sample at ages 70 and 78, it was only possible to include cognitive status as a co variable at age 85. The inclusion of MMSE ≤24 into both functional models at age 85 served to further diminish the already non-significant mortality HR associated with handrail use. In order to address the possibility of reverse causality, whereby proximity to death (for any number of reasons) influenced the ability to climb stairs unassisted, we performed sensitivity analyses whereby subjects who died within the first six months of follow-up periods were excluded from the Coxproportional Hazards Ratio analysis. No significant changes in either overall magnitude or direction of results were found. The only changes observed were that the HR for using a handrail at age 78-85 in the functional model 1 decreased from 1.66 (95%CI 1.16-2.39) to 1.51 (95%CI 0.91-2.68), and the HR at age 85-90 in the medical model at age 85 increased from 1.43 (95%CI 0.92-2.23) to 1.73 (95%CI 1.09-2.7).
Figure 1 Handrail use and survival
Discussion In this study of a representative sample of community dwelling older people, we describe the increasing frequency of handrail use to climb stairs with rising age, and the consistent profile of a wide spectrum of negative health parameters associated with handrail use at ages 70, 78 and 85. Handrail use, at all ages examined, was a consistent predictor of longterm mortality after adjusting for demographic, social and common medical conditions. Between the ages 78-85 and 78-90 the predictive value of handrail use remained significant even after adjusting for common functional parameters, however this effect was not observed at other periods during follow-up. Excluding subjects with mortality less than six months only served to strengthen the predictive value of handrail use upon subsequent mortality. At age 70 and 85, adjusting for functional co variables weakened the association observed between handrail use and mortality. These finding suggest that the association with, and predictive value of handrail use on mortality is largely manifest through the influence of functional impairments, and while handrail use may serve as an early indicator and potential predictor of subsequent mortality, it is in all likelihood a proxy measure associated with declining functional status
Kaplan-Meier survival charts according to handrail use showing survival from ages 70-78, 78-85, and 85-90, with log-rank p-values shown in figures.
As shown in Table 2 and Figure 1, survival was significantly lower among subjects of all ages who reported needing to use a handrail to climb stairs. Accordingly, unadjusted mortality Hazard Ratios associated with handrail use at age 70, 78 and 85 and mortality from ages 70-78, 70-90, 78-85, 78-90 and 85-90 were HR 1.57 (95%CI, 1.01-2.42), HR 1.65 (95%CI, 1.27-2.14), HR 1.78 (95%CI, 1.41-2.25), HR 1.71 (95%CI, 1.41-2.06), and HR 1.53 (95%CI, 1.01-2.33) respectively. The increased likelihood of mortality associated with using a handrail to climb stairs remained significant after adjusting for 4
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THE JOURNAL OF NUTRITION, HEALTH & AGING© and poor health. Trajectories of accelerated functional decline and subsequent increased mortality associated with handrail use hardly seem surprising. The clinical profile described among handrail users included multiple impairments across domains of cognition, mood, pain, vision, hearing, BMI, falls, grip strength, low physical activity, fatigue, and chronic illness. Similarly, in logistic regression analyses the strongest significant predictors were female gender, poor financial status, poor self rated health, low physical activity level, difficulty in activities of daily living, BMI and number of medications. Whether defined according to frailty phenotype (21), cognitive frailty (22), sarcopenia (23), or cumulative deficits (24), using a handrail to climb stairs would appear to frequently accompany an underlying state of frailty, with all the associated prognostic implications. Recent studies into self reported difficulty in stair negotiating performance have also provided insight into the wider clinical profile, including for example chronic illness, arthritis, and depression (4) in a study of 310 subjects, average age 79 years, as well as self rated health, chronic pain, vitality, vision, peripheral sensation, depression, and fear of falling in addition to sensorimotor, balance and biomechanical variables, among a sample of 664 subjects mean age 80 years (7). The authors noted that only 50% of variance in handrail use could be attributed the variables examined, concluding that additional factors were clearly involved. The extensive profile of parameters which were associated with handrail use in the current study was shown to be consistent at ages 70, 78 and 85, and the breadth of parameters reported coupled with the relative stability of the associations over 15 years of follow-up has not been documented previously. Predicting decline among older people is a major challenge facing health professionals both in planning for subsequent care needs, as well as highlighting the need for early potential strategies for prevention and intervention. Simple performance measures such as walking speed, grip strength, timed up-andgo, may be helpful clinical tools in helping identify older people at risk for subsequent decline. The use of self reported difficulty negotiating stairs has previously been reported as a predictor of subsequent functional decline (8) among a sample of 513 people, aged on average 81, with average follow up of 1.8 years. A novel finding to emerge from our study was the ability of hand rail use to predict long-term mortality throughout follow-up at age 70-78, 78-85, and 85-90, as well as throughout the longer periods from 70-90, and 78-90 years. Interestingly, this effect was independent of sociodemographic and common medical factors throughout follow up, as well as functional co variables at age 78-85 and 78-90, supporting the notion that handrail use is a surrogate measure reflecting a multitude of sensorimotor, affective, cognitive, lifestyle and traditional functional parameters. Difficulty negotiating stairs and declining mobility for many older people are among the earliest impairments (6) and serve as portals into the process of disability, disengagement from
an active lifestyle, and becoming increasingly housebound. Recent epidemiological data from the US suggest that the prevalence of housebound individual in the US in 2011 was 5.6% (25), among whom only 11.9% actually received primary care services. Whilst current attitudes to “aging in place” emphasize the importance of continuity of placement, nonetheless planning and provision of appropriate living environments in the community are often far from being optimal. Frequently, decisions to leave the home in favor of alternative care environments are based upon issues of mobility in general and stair negotiation in particular. On a practical note, the clinical ramifications of our findings highlight the importance in recognizing that individuals with difficulty negotiating stairs are at risk for increased mortality, which in the correct scenario should serve to stimulate health care professionals in their accurate assessment of patients’ needs and care. Indeed there is a growing awareness of the need for implementation of screening for early signs of frailty into daily clinical practice (26), and novel technologies may help prevention of disability and enhance the well-being of frail elderly. Traditional assessment instruments are likely to be complemented with measures of frailty domains (27), and our findings would seem to suggest that using a handrail may indeed serve as early sign of impending decline. Limitations of this study exist. The breadth of data collected by necessity limited the detail of data collection on any specific topic. Thus, for example, detailed analyses of gait were not performed, and tools measuring performance of stair negotiation were absent. Studies have emphasized the different biomechanics of climbing versus descending stairs (4), however our data covered stair climbing only. Our findings are drawn from a representative population of older Jerusalem residents, and thus comparisons and conclusions to other populations require caution. However, the overall sample population are extremely varied in their origin, with over 40 different countries of birth, and the heterogeneity might to some extent overcome culturally bound areas of research. Furthermore, comparison of data sets from our cohort are very similar to other similar aged cohorts in different countries, for a range of demographic, social, functional as well as medical characteristics (28, 29). In conclusion, this study found that the need to use a handrail to climb stairs progressively increased with rising age, was associated with a wide profile of negative health parameters, and was significantly predictive of subsequent mortality. Funding: This work was supported by funds from the Ministry of Senior Citizens of the State of Israel, and Eshel- the Association for the Planning and Development of Services for the Aged in Israel. These funds were used exclusively to support the research effort, primarily as salaries to ancillary staff. No research funds were received by any author of this paper.
Acknowledgments: The sponsors had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review, or approval of the manuscript. Author Contributions: JS and JMJ had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: JS ,JMJ,YR, Acquisition of data: JS, JMJ, YR, Analysis
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STAIRS, HANDRAIL, AND SURVIVAL Appendix Table 3 Predictors of handrail use at age 70, 78 and 85: Results of logistic regression analyses for sociodemographic, functional and medical models age 70 Parameter
OR
CI 95%
age 78
age 85
p value
OR
CI 95%
p value
OR
CI 95%
p value
Sociodemographic Model Female gender
2.08
(1.2, 3.62)
0.01
2.61
(1.75, 3.92)
<0.0001
3.22
(1.99, 5.22)
<0.0001
Marital status (married)
1.32
(0.55, 3.23)
0.5388
2.11
(0.91, 4.91)
0.084
0.91
(0.34, 2.51)
0.8614
Low Educational level (≤12 years)
1.84
(1.12, 3.04)
0.0172
1.97
(1.38, 2.82)
0.0002
1.24
(0.84, 1.83)
0.2921
Poor financial status
1.98
(1.15, 3.41)
0.0138
2.85
(1.7, 4.8)
<0.0001
1.82
(0.95, 3.49)
0.0715
Smoking (ever)
0.82
(0.37, 1.82)
0.6228
1.17
(0.58, 2.39)
0.6654
1.02
(0.68, 1.55)
0.9301
BMI (continuous) kg/m2
1.05
(1, 1.12)
0.0959
1.09
(1.05, 1.13)
<0.0001
1.09
(1.04, 1.15)
0.0008
Poor self-rated health
1.41
(0.72, 2.79)
0.318
2.28
(1.42, 3.66)
0.001
1.98
(0.98, 3.99)
0.058
Fatigue
1.15
(0.58, 2.26)
0.692
1.42
(0.91, 2.23)
0.122
2.40
(1.57, 3.68)
<.0001
Depression
0.92
(0.42, 2.02)
0.829
1.19
(0.07, 2.00)
0.527
1.01
(0.58, 1.74)
0.9739
Low Physical Activity
3.53
(1.92, 6.47)
<.0001
2.64
(1.48, 4.69)
0.001
4.36
(1.94, 9.79)
0.0004
Poor sleep satisfaction
1.56
(0.83, 2.96)
0.169
0.92
(0.55, 1.53)
0.738
1.06
(0.65, 1.72)
0.8266
BADL difficulty
5.88
(2.7, 12.81)
<.0001
4.98
(2.71, 9.14)
<.0001
1.63
(0.97, 2.74)
0.0647
Chronic pain
1.02
(0.55, 1.89)
0.948
1.16
(0.70, 1.92)
0.574
1.76
(1.05, 2.96)
0.0315
Fall ≥1 in last year
1.59
(0.87, 2.90)
0.131
2.10
(1.33, 3.29)
0.001
1.46
(0.94, 2.26)
0.089
Hypertension
1.16
(0.71, 1.93)
0.5535
1.36
(1, 1.84)
0.0497
1.24
(0.82, 1.91)
0.3132
Diabetes Mellitus
0.94
(0.51, 1.73)
0.8333
1.53
(1.06, 2.23)
0.0253
1.06
(0.61, 1.84)
0.8418
Ischemic Heart Disease
0.99
(0.58, 1.72)
0.9694
1.23
(0.9, 1.7)
0.2059
1.05
(0.68, 1.65)
0.8258
Cancer
2.22
(0.78, 6.38)
0.1385
0.71
(0.38, 1.32)
0.2704
2.50
(0.99, 6.36)
0.0544
Medication (number)
1.08
(1.02, 1.15)
0.0212
1.03
(1, 1.06)
0.0469
1.09
(1.05, 1.14)
<0.0001
Functional Model
Medical Model
* Minimental State Examination score was not included in the model due to insufficient numbers (see Table 1) and interpretation of data: JMJ, JS, YR, Drafting of the manuscript:, JMJ, JS, YR; Critical revision of the manuscript for important intellectual content: JS, JMJ, YR, Statistical analyses: JMJ, JS, YR, Administrative, technical, or material support: JS, Obtained funding, study supervision: JS.
7. 8.
Conflict of interest: There were no conflicts of interests or financial disclosures involved in the undertaking of this study for any of the authors.
9.
Ethical Standards: Each participant, or legal guardian, provided informed consent, and the Hadassah-Hebrew University Medical Center Institutional Review Board approved the study.
10.
References 1. 2. 3. 4. 5. 6.
11. 12.
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