Housing conditions and risk of physical function limitations: a prospective study of community-dwelling older adults

Housing conditions and risk of physical function limitations: a prospective study of... Abstract Background Poor housing conditions have been associated with an increased risk of morbidity and mortality in old age. Methods Prospective cohort of 1602 older adults followed from 2012 to 2015. Poor conditions were defined as living in a walk-up building, lacking piped hot water or heating, feeling frequently cold at home, lacking a bathtub/shower, a refrigerator, a washing machine, an own room or a landline. Frailty was assessed with the Fried criteria, lower extremities performance with the Short Physical Performance Battery (SPPB), and disability in instrumental activities of daily living (IADL) with the Lawton and Brody questionnaire. Results During follow-up, 55 individuals (4.2%) developed frailty and 107 (7.2%) IADL disability. Mean (SD) SPPB values at baseline and at follow-up were 8.5 (2.5) and 8.6 (2.4), respectively. After multivariate adjustment, participants who lived in homes with ≥1 poor conditions showed a higher risk of frailty (odds ratio [OR] = 2.02; 95% confidence interval [95% CI]: 1.09–3.75) and transportation disability (OR = 3.50; 95% CI: 1.38–8.88). Lacking heating and feeling frequently cold were associated with an increased risk of exhaustion (OR = 2.34; 95% CI: 1.00-5.48) and transportation disability (OR = 3.31; 95% CI: 1.07–10.2), respectively. Conclusions Prevention programs targeting functional limitations in older adults should ensure that they live in suitable housing conditions. frailty, physical function, social inequalities Introduction Declines in functional ability with age are a consequence of the accumulation of deficits in multiple biological systems and are important predictors of disability, hospitalization, institutionalization and death.1–3 In this context, the WHO defines ‘healthy ageing’ as the process of developing and maintaining the functional ability that enables wellbeing in older age, and stresses the need to promote age-friendly environments (i.e. supported living housing options) to raise overall levels of ability in the older population.4 Several studies have shown that poor housing conditions in older adults, including lack of basic facilities (i.e. bath or shower), accessibility problems or inadequate indoor temperature control, are associated with worse health outcomes,5–8 and higher risk of disease-specific and all-cause mortality.9–11 However, less is known regarding the influence of poor housing conditions on functional status in older adults, with a few cross-sectional6,12–14 and only one longitudinal15 study having suggested they may be associated. One of the cross-sectional studies, based on 7997 adults aged ≥50 years from the English Longitudinal Study of Ageing, showed worse handgrip strength values in participants who resided in homes with measured temperatures <18°C, when compared to their counterparts.6 Another, based on 848 community-dwelling 75–90-year-old adults from the ‘Life-space mobility in old age’ cohort, showed that at home entrance-related barriers were associated with limitations in lower extremity performance as assessed with the Short Physical Performance Battery (SPPB). Similarly, in a previous cross-sectional study using data from 2 012 non-institutionalized individuals aged ≥60 years in Spain, we observed that living in a walk-up building (i.e. an apartment block or a storey house without an elevator), lacking heating and self-reporting feeling frequently cold at home were associated with a wide variety of physical function limitations, including worse performance in the SPPB test and a higher prevalence of frailty and four of its components (exhaustion, slow walking speed, low physical activity and weakness).12 Finally, in the only existing longitudinal study, authors from the ENABLE-AGE project showed an association between baseline number of accessibility problems in the home environment and risk of developing disability in activities of daily living (ADL).15 To extend previous cross-sectional findings, we here examine the prospective association between housing conditions and the incidence of a wide variety of physical functioning limitations among older adults participating in the Seniors-ENRICA (Study on Nutrition and Cardiovascular Risk in Spain) cohort. Methods Study population and design A cross-sectional survey of 11 911 individuals’ representative of the non-institutionalized population aged ≥18 years in Spain was conducted between 2008 and 2010 (ENRICA study).10 Survey participants were selected by stratified cluster sampling according to province (the 50 provinces of Spain) and size of municipality (10 000, 10 000–100 000, 100 000–500 000, >500 000 population). Clusters were then selected randomly in two stages: municipalities and census sections. Finally, households within each section were selected by random telephone dialing using the directory of telephone land-lines as the sampling frame. Subjects in the households were selected proportionally to the distribution of the population of Spain by sex and age group.16 Participants aged ≥60 years from ENRICA (n = 2614; baseline wave or wave 1) were invited to participate in the Seniors-ENRICA, a follow-up study consisting in biannual phone interviews and home visits to obtain information on socio-demographic factors, lifestyle and morbidity, collect biological samples, perform a physical exam and obtain a diet history. All participants gave informed consent, and the Clinical Research Ethics Committee of the La Paz University Hospital in Madrid approved the study.10 During follow-up (waves 2 (2012) and 3 (2015)), 177 participants died and 616 were lost to follow-up, so information in 2015 was obtained among 1821 individuals. Subjects lost to follow-up were older, had a lower educational level, and showed a higher prevalence of morbidities and functional limitations. From the 1821 participants in 2015, we excluded 40 subjects without complete data on housing conditions or potential confounders. Additionally, for analyses based on the SPPB score we excluded those who lacked information on this variable, either at baseline or at follow-up (n = 179), leading to a sample size of 1 602 participants. Similarly, for analyses based on frailty and instrumental activities of daily living (IADL) disability, we excluded those participants with no complete information on these items (n = 395, n = 182, respectively), as well as those who were frail (n = 75), or had IADL limitations (n = 105) at baseline, so that analyses were performed with 1311 and 1494 participants, respectively. Study variables Housing conditions The following questions were asked: (i) Do you live in an apartment building with no elevator? (ii) Do you have piped hot water at home? (iii) Do you have a heating system at home? (iv) Do you frequently feel cold at home? (v) Do you have a bathtub or shower? (vi) Do you have a refrigerator? (vii) Do you have a washing machine? (viii) Do you have a landline at home? (ix) Do you have a room of your own? A score of 1 was assigned for the absence of each of these services or for feeling cold; and a scale ranging from 0 to 9 was constructed by summing the scores across the 9 items. This questionnaire has previously been shown to predict mortality among patients with heart failure.11 Individuals were classified into two categories: those with no poor conditions and those with ≥1 poor conditions. Because most conditions were only present in nine participants, we could only assess the specific association between those items with a higher prevalence (‘living in a walk-up building’, ‘lacking heating’ and ‘feeling frequently cold’) and the risk of functional limitations. Limitations in physical function Lower extremity function was assessed using the SPPB test, frailty using the Fried criteria, and disability in instrumental activity of daily living (IADL) using the Lawton and Brody test. These instruments have been used in previous studies to assess physical functioning in older adults.12,17,18 The SPPB test included three components: balance, walking speed and ability to rise from a chair. Each component was assigned a score ranging from 0 to 4, and the total SPPB result was calculated by the sum of the three components.18 A higher score in each test and across them indicated better performance. Individuals were considered frail if they met ≥3 of 5 Fried criteria,19 and pre-frail if they met 1 or 2. The 5 Fried criteria were defined as follows: (1) Exhaustion: any of the following responses to two questions taken from the Center for Epidemiologic Studies Depression Scale: ‘I felt that everything I did was a big effort’ or ‘I felt that I could not keep on doing things’ at least 3–4 days a week; (2) weakness: lowest quintile in the study sample of grip strength, measured with a Jamar dynamometer and adjusted for sex and body mass index (BMI), with the highest value in two consecutive measures used in the analyses; (3) weight loss: unintentional loss of ≥4.5 kg of body weight in the preceding year; (4) low physical activity: walking ≤2.5 h/week in men and ≤2 h/week in women; and (5) slow walking speed: lowest quintile in the study sample for the three meter walking speed test, adjusted for sex and height. Finally, the Lawton and Brody scale20 evaluated the individual´s ability to use the telephone, go shopping, prepare meals, do the housework, do the laundry, use different means of transportation, take medication, and manage finances. Due to cultural issues, the questions on meal preparation, housework and laundry were excluded in men; thus, summary scores ranged from 0 to 5 in men, and from 0 to 8 in women. Individuals with disability in one or more of these activities were considered as IADL disabled. Other variables During telephone interviews, information was obtained on age, sex, education, occupation, tobacco consumption, physical activity and sedentary behavior. Physical activity was assessed with the validated questionnaire developed from that used in the EPIC-cohort study in Spain,21 and expressed in metabolic equivalent-hours/day. Subjects reported their participation in the following recreational activities: walking, cycling and practicing sports other than cycling (mainly running, playing soccer, doing aerobics, swimming and playing tennis); as well as in the following household activities: household chores (cleaning, cooking, doing laundry, children rearing). The assigned metabolic equivalent (MET) values (using the EPIC data manual guidelines) were 3.0 for walking and house-working and 6.0 for cycling and sports. Sedentary behavior was defined as the number of hours/day spent watching TV. Participants also reported their physician-diagnosed morbidity (ischemic heart disease, stroke, heart failure, diabetes, cancer, asthma, chronic bronchitis, osteoarthritis, arthritis or hip fracture). At home, weight and height measurements were performed twice, using electronic scales (model Seca 841, precision to 0.1 kg) and portable extendable stadiometers (model Ka We 44 444Seca). Mean values of the two measurements were used for analyses, and BMI was calculated as the weight in kg divided by the square height in meter. Statistical analysis Linear regression was used to assess the prospective association between housing conditions and the SPPB score, while logistic regression was used to assess the association between housing conditions and risk of frailty and its components, or risk of IADL disability. We fitted two regression models. Model 1 adjusted for age, sex and educational level; and model 2 further adjusted for smoking status (never, ex-smoker, current-smoker), physical activity (MET-h/week), sedentary behavior (hours watching television/week), BMI (<25, 25–29.9, ≥30 kg/m2) and morbidity (cancer, diabetes, cardiovascular disease, osteomuscular disease, chronic respiratory disease). Models based on the SPPB score further adjusted for its baseline value. Statistical significance was set at two-sided P < 0.05. All analyses were performed using STATA version 13.0, (College Station, TX: Stata Corp LP). Results Among study participants, 48% lived in a walk-up building, 4% lacked heating and 6% felt frequently cold. The average (SD) number of poor conditions was 0.59 (0.64). Table 1 shows the main baseline characteristics of study participants by housing conditions. Individuals with ≥1 poor housing conditions were less educated and had a higher prevalence of obesity and osteomuscular disease. Table 1 Age- and sex- adjusted baseline characteristics of older adults by housing conditions N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 Continuous variables are presented as mean (standard deviations). SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living. Table 1 Age- and sex- adjusted baseline characteristics of older adults by housing conditions N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 Continuous variables are presented as mean (standard deviations). SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living. During follow-up, 55 individuals (4.2%) developed incident frailty and 107 (7.2%) incident disabilities. Mean (SD) SPPB values at baseline and at follow-up were 8.5 (2.5) and 8.6 (2.4), respectively. After multivariate adjustment (model 2), participants who lived in homes with ≥1 poor condition showed similar SBBP scores at follow-up than those who lived in homes where the three services were present (beta: 0.01; 95% confidence interval [CI]: −0.20 to 0.21); however, higher risks of frailty (OR = 2.02; 95% CI: 1.09–3.75) were observed among those living in homes with ≥1 poor condition (Table 2). Table 2 Association between housing conditions and risk of limitations in physical function among older adults followed from 2008–2010 to 2015 in Spain SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living; CI, confidence interval; OR, odds ratio. Beta coefficients and their 95% confidence intervals were obtained from multivariate lineal regression models. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. Model 1 is adjusted for age, sex, educational level (≤primary, secondary, university). Linear regression models were also adjusted for the baseline SPPB score. Model 2 is adjusted as model 1 plus smoking status (never, ex-smoker, current-smoker), physical activity (MET-h/week), watching TV (h/week), BMI (<25, 25–29.9, ≥30 kg/m2) and comorbidities (cancer, diabetes, cardiovascular disease, osteomuscular disease, chronic respiratory disease). Statistically significant results are presented in bold. Table 2 Association between housing conditions and risk of limitations in physical function among older adults followed from 2008–2010 to 2015 in Spain SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living; CI, confidence interval; OR, odds ratio. Beta coefficients and their 95% confidence intervals were obtained from multivariate lineal regression models. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. Model 1 is adjusted for age, sex, educational level (≤primary, secondary, university). Linear regression models were also adjusted for the baseline SPPB score. Model 2 is adjusted as model 1 plus smoking status (never, ex-smoker, current-smoker), physical activity (MET-h/week), watching TV (h/week), BMI (<25, 25–29.9, ≥30 kg/m2) and comorbidities (cancer, diabetes, cardiovascular disease, osteomuscular disease, chronic respiratory disease). Statistically significant results are presented in bold. Table 3 shows the association between housing conditions and risk of each frailty criterion among individuals who were robust, or pre-frail but free of the specific criterion of interest, at baseline. Older adults living in homes with ≥1 poor condition showed an increased risk of low physical activity (OR = 1.42; 95% CI: 1.00–2.03), mainly due to their homes lacking an elevator and adequate temperature control. Individuals living in homes with no heating also showed an increased risk of exhaustion (OR = 2.34; 95% CI: 1.00–5.48). Table 3 Association between housing conditions and risk of each criterion of frailty among Spanish older adults who were free of the criterion of interest at baseline Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. Table 3 Association between housing conditions and risk of each criterion of frailty among Spanish older adults who were free of the criterion of interest at baseline Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. Results from Table 4 show that the presence of ≥1 poor housing condition was associated with an increased risk of transportation disability (OR = 3.50; 95% CI: 1.38–8.88) among older adults who were free from IADL disabilities at baseline. In particular, those frequently feeling cold showed the highest risks of transportation disability (OR = 3.31; 95% CI: 1.07–10.21). Table 4 Association between housing conditions and risk of each disability in instrumental activities of daily living (IADL) among Spanish older adults free of IADL disabilities at baseline Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. aMeal preparation, housework and laundry are excluded in men. bThe item ‘ability to use the telephone’ has been excluded from the table because only one individual had limitations in this item. Table 4 Association between housing conditions and risk of each disability in instrumental activities of daily living (IADL) among Spanish older adults free of IADL disabilities at baseline Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. aMeal preparation, housework and laundry are excluded in men. bThe item ‘ability to use the telephone’ has been excluded from the table because only one individual had limitations in this item. As sensitivity analyses, we evaluated the risk of presenting an SPPB score over 9 and analyzed the IADL scale as a continuous variable, and we obtained similar results (please see Supplementary Table S1). Discussion Main finding of this study Results add to our previous cross-sectional observations showing that older adults living in poor housing are at increased risk of frailty.12 However, they do not support a prospective relationship between living conditions and risk of poor lower extremity performance or IADL disability. What is already known on this topic Ageing in place is considered to support older adults to live independently. However, only a few studies have evaluated whether certain home features may be associated with the risk of functional limitations in community-dwelling older adults. To our knowledge, this is the first study to investigate the association between poor housing conditions and risk of frailty or IADL disability, and the first to prospectively evaluate the association between home characteristics and reduced SPPB scores. Living in walk-up apartments may prevent older adults from going outdoors, an activity that has been prospectively associated with functional and intellectual health benefits among this subpopulation.22–25 Moreover, there is evidence in the literature that homebound older adults are at increased risk of sedentariness,26 nutritional deficiencies27,28 and depression,29 all of which are known risk factors of frailty and disability.17,30–32 There is also strong evidence that cold homes have a harmful effect on health, especially among older people, who have reduced thermoregulatory control and thermal discrimination.33,34 However, previous studies focusing on the effects of cold temperatures on functional outcomes are scarce and lack follow-up evaluations.6,12,35,36 One of the existing cross-sectional studies, with 88 women randomly exposed to 15 and 25°C climate chambers, showed decreased gait speed and worse extremity performance with lower room temperatures.35 Another, showed worse handgrip strength values in UK participants who resided in homes with measured temperatures <18°C when compared to their counterparts.6 Finally, in our own cross-sectional study we found that ‘lacking heating’ and, to a less extent, ‘feeling frequently cold’ were associated with worse extremity performance and higher prevalence of frailty and some of its components, but not with the prevalence of IADL disability.12 Although some of the present analyses failed to find significant outcome differences, they suggest that ‘feeling frequently cold’ may be a risk factor of frailty and transportation disability, while support our previous findings that lacking heating is associated with the risk of developing exhaustion. What this study adds In our study, participants with ≥1 poor conditions had a 0.8% higher absolute risk of frailty, a 0.9% higher absolute risk of transportation disability, and a 1.34% higher absolute risk of low physical activity per year of follow-up. Given the high prevalence of poor housing, with 52% of the study cohort presenting ≥1 poor condition, these findings have substantial public health relevance. Limitations of this study Among the potential limitations of this study is the low prevalence of exposure to some of the exposures of interest (i.e. lack of piped hot water at home), the lack of temperature measurements, as well as the low incidence of some of the studied outcomes (i.e. IADL disability), all of which could have prevented us from detecting some existing associations. Despite this, we did observe a strong and clinically relevant association between housing conditions and frailty and some of its components. As an additional disadvantage, our results cannot be extrapolated to older populations living in countries with major differences in climate or urban planning, as well as to institutionalized populations. Moreover, as in other cohorts with older adults, the sample size decreased over time because of a substantial number of deaths and losses to follow-up. Given that individuals lost to follow-up showed a higher prevalence of morbidities and functional limitations at baseline, participants who remained in poor housing conditions may represent a ‘survivor cohort’ of people who are fit enough to remain in their usual homes. The main strengths of this study include its longitudinal design, the use of validated measures of physical function in older adults, and the adjustment for good number of covariates, which reduces the probability of residual confounding. Conclusion Our results support the role of poor housing conditions in the development of frailty. Prevention programs targeting functional limitations and disability in older people should ensure that older adults live in homes that are accessible to the street and have adequate temperature systems. Funding This work was supported by a grant from CIBERESP, FIS grants 16/609 and 13/0288 (Instituto de Salud Carlos III, State Secretary of R+D+I and FEDER/FSE), the FRAILOMIC Initiative (European Union FP7-HEALTH-2012-Proposal no. 305483-2) and the ATHLOS project (European project H2020- Project ID: 635316). The funding agencies had no role in study design, data analysis, interpretation of results, article preparation or in the decision to submit this article for publication. Conflict of interest We have no conflicts of interest to declare. References 1 Cooper R , Kuh D , Cooper C et al. . Objective measures of physical capability and subsequent health: a systematic review . Age Ageing 2011 ; 40 : 14 – 23 . 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Google Scholar Crossref Search ADS PubMed 35 Lindemann U , Oksa J , Skelton DA et al. . Effect of cold indoor environment on physical performance of older women living in the community . Age Ageing 2014 ; 43 : 571 – 5 . Google Scholar Crossref Search ADS PubMed 36 Greaney JL , Stanhewicz AE , Kenney WL et al. . Muscle sympathetic nerve activity during cold stress and isometric exercise in healthy older adults . J Appl Physiol 1985 ; 2014 ( 117 ): 648 – 57 . © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

Housing conditions and risk of physical function limitations: a prospective study of community-dwelling older adults

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© The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Abstract

Abstract Background Poor housing conditions have been associated with an increased risk of morbidity and mortality in old age. Methods Prospective cohort of 1602 older adults followed from 2012 to 2015. Poor conditions were defined as living in a walk-up building, lacking piped hot water or heating, feeling frequently cold at home, lacking a bathtub/shower, a refrigerator, a washing machine, an own room or a landline. Frailty was assessed with the Fried criteria, lower extremities performance with the Short Physical Performance Battery (SPPB), and disability in instrumental activities of daily living (IADL) with the Lawton and Brody questionnaire. Results During follow-up, 55 individuals (4.2%) developed frailty and 107 (7.2%) IADL disability. Mean (SD) SPPB values at baseline and at follow-up were 8.5 (2.5) and 8.6 (2.4), respectively. After multivariate adjustment, participants who lived in homes with ≥1 poor conditions showed a higher risk of frailty (odds ratio [OR] = 2.02; 95% confidence interval [95% CI]: 1.09–3.75) and transportation disability (OR = 3.50; 95% CI: 1.38–8.88). Lacking heating and feeling frequently cold were associated with an increased risk of exhaustion (OR = 2.34; 95% CI: 1.00-5.48) and transportation disability (OR = 3.31; 95% CI: 1.07–10.2), respectively. Conclusions Prevention programs targeting functional limitations in older adults should ensure that they live in suitable housing conditions. frailty, physical function, social inequalities Introduction Declines in functional ability with age are a consequence of the accumulation of deficits in multiple biological systems and are important predictors of disability, hospitalization, institutionalization and death.1–3 In this context, the WHO defines ‘healthy ageing’ as the process of developing and maintaining the functional ability that enables wellbeing in older age, and stresses the need to promote age-friendly environments (i.e. supported living housing options) to raise overall levels of ability in the older population.4 Several studies have shown that poor housing conditions in older adults, including lack of basic facilities (i.e. bath or shower), accessibility problems or inadequate indoor temperature control, are associated with worse health outcomes,5–8 and higher risk of disease-specific and all-cause mortality.9–11 However, less is known regarding the influence of poor housing conditions on functional status in older adults, with a few cross-sectional6,12–14 and only one longitudinal15 study having suggested they may be associated. One of the cross-sectional studies, based on 7997 adults aged ≥50 years from the English Longitudinal Study of Ageing, showed worse handgrip strength values in participants who resided in homes with measured temperatures <18°C, when compared to their counterparts.6 Another, based on 848 community-dwelling 75–90-year-old adults from the ‘Life-space mobility in old age’ cohort, showed that at home entrance-related barriers were associated with limitations in lower extremity performance as assessed with the Short Physical Performance Battery (SPPB). Similarly, in a previous cross-sectional study using data from 2 012 non-institutionalized individuals aged ≥60 years in Spain, we observed that living in a walk-up building (i.e. an apartment block or a storey house without an elevator), lacking heating and self-reporting feeling frequently cold at home were associated with a wide variety of physical function limitations, including worse performance in the SPPB test and a higher prevalence of frailty and four of its components (exhaustion, slow walking speed, low physical activity and weakness).12 Finally, in the only existing longitudinal study, authors from the ENABLE-AGE project showed an association between baseline number of accessibility problems in the home environment and risk of developing disability in activities of daily living (ADL).15 To extend previous cross-sectional findings, we here examine the prospective association between housing conditions and the incidence of a wide variety of physical functioning limitations among older adults participating in the Seniors-ENRICA (Study on Nutrition and Cardiovascular Risk in Spain) cohort. Methods Study population and design A cross-sectional survey of 11 911 individuals’ representative of the non-institutionalized population aged ≥18 years in Spain was conducted between 2008 and 2010 (ENRICA study).10 Survey participants were selected by stratified cluster sampling according to province (the 50 provinces of Spain) and size of municipality (10 000, 10 000–100 000, 100 000–500 000, >500 000 population). Clusters were then selected randomly in two stages: municipalities and census sections. Finally, households within each section were selected by random telephone dialing using the directory of telephone land-lines as the sampling frame. Subjects in the households were selected proportionally to the distribution of the population of Spain by sex and age group.16 Participants aged ≥60 years from ENRICA (n = 2614; baseline wave or wave 1) were invited to participate in the Seniors-ENRICA, a follow-up study consisting in biannual phone interviews and home visits to obtain information on socio-demographic factors, lifestyle and morbidity, collect biological samples, perform a physical exam and obtain a diet history. All participants gave informed consent, and the Clinical Research Ethics Committee of the La Paz University Hospital in Madrid approved the study.10 During follow-up (waves 2 (2012) and 3 (2015)), 177 participants died and 616 were lost to follow-up, so information in 2015 was obtained among 1821 individuals. Subjects lost to follow-up were older, had a lower educational level, and showed a higher prevalence of morbidities and functional limitations. From the 1821 participants in 2015, we excluded 40 subjects without complete data on housing conditions or potential confounders. Additionally, for analyses based on the SPPB score we excluded those who lacked information on this variable, either at baseline or at follow-up (n = 179), leading to a sample size of 1 602 participants. Similarly, for analyses based on frailty and instrumental activities of daily living (IADL) disability, we excluded those participants with no complete information on these items (n = 395, n = 182, respectively), as well as those who were frail (n = 75), or had IADL limitations (n = 105) at baseline, so that analyses were performed with 1311 and 1494 participants, respectively. Study variables Housing conditions The following questions were asked: (i) Do you live in an apartment building with no elevator? (ii) Do you have piped hot water at home? (iii) Do you have a heating system at home? (iv) Do you frequently feel cold at home? (v) Do you have a bathtub or shower? (vi) Do you have a refrigerator? (vii) Do you have a washing machine? (viii) Do you have a landline at home? (ix) Do you have a room of your own? A score of 1 was assigned for the absence of each of these services or for feeling cold; and a scale ranging from 0 to 9 was constructed by summing the scores across the 9 items. This questionnaire has previously been shown to predict mortality among patients with heart failure.11 Individuals were classified into two categories: those with no poor conditions and those with ≥1 poor conditions. Because most conditions were only present in nine participants, we could only assess the specific association between those items with a higher prevalence (‘living in a walk-up building’, ‘lacking heating’ and ‘feeling frequently cold’) and the risk of functional limitations. Limitations in physical function Lower extremity function was assessed using the SPPB test, frailty using the Fried criteria, and disability in instrumental activity of daily living (IADL) using the Lawton and Brody test. These instruments have been used in previous studies to assess physical functioning in older adults.12,17,18 The SPPB test included three components: balance, walking speed and ability to rise from a chair. Each component was assigned a score ranging from 0 to 4, and the total SPPB result was calculated by the sum of the three components.18 A higher score in each test and across them indicated better performance. Individuals were considered frail if they met ≥3 of 5 Fried criteria,19 and pre-frail if they met 1 or 2. The 5 Fried criteria were defined as follows: (1) Exhaustion: any of the following responses to two questions taken from the Center for Epidemiologic Studies Depression Scale: ‘I felt that everything I did was a big effort’ or ‘I felt that I could not keep on doing things’ at least 3–4 days a week; (2) weakness: lowest quintile in the study sample of grip strength, measured with a Jamar dynamometer and adjusted for sex and body mass index (BMI), with the highest value in two consecutive measures used in the analyses; (3) weight loss: unintentional loss of ≥4.5 kg of body weight in the preceding year; (4) low physical activity: walking ≤2.5 h/week in men and ≤2 h/week in women; and (5) slow walking speed: lowest quintile in the study sample for the three meter walking speed test, adjusted for sex and height. Finally, the Lawton and Brody scale20 evaluated the individual´s ability to use the telephone, go shopping, prepare meals, do the housework, do the laundry, use different means of transportation, take medication, and manage finances. Due to cultural issues, the questions on meal preparation, housework and laundry were excluded in men; thus, summary scores ranged from 0 to 5 in men, and from 0 to 8 in women. Individuals with disability in one or more of these activities were considered as IADL disabled. Other variables During telephone interviews, information was obtained on age, sex, education, occupation, tobacco consumption, physical activity and sedentary behavior. Physical activity was assessed with the validated questionnaire developed from that used in the EPIC-cohort study in Spain,21 and expressed in metabolic equivalent-hours/day. Subjects reported their participation in the following recreational activities: walking, cycling and practicing sports other than cycling (mainly running, playing soccer, doing aerobics, swimming and playing tennis); as well as in the following household activities: household chores (cleaning, cooking, doing laundry, children rearing). The assigned metabolic equivalent (MET) values (using the EPIC data manual guidelines) were 3.0 for walking and house-working and 6.0 for cycling and sports. Sedentary behavior was defined as the number of hours/day spent watching TV. Participants also reported their physician-diagnosed morbidity (ischemic heart disease, stroke, heart failure, diabetes, cancer, asthma, chronic bronchitis, osteoarthritis, arthritis or hip fracture). At home, weight and height measurements were performed twice, using electronic scales (model Seca 841, precision to 0.1 kg) and portable extendable stadiometers (model Ka We 44 444Seca). Mean values of the two measurements were used for analyses, and BMI was calculated as the weight in kg divided by the square height in meter. Statistical analysis Linear regression was used to assess the prospective association between housing conditions and the SPPB score, while logistic regression was used to assess the association between housing conditions and risk of frailty and its components, or risk of IADL disability. We fitted two regression models. Model 1 adjusted for age, sex and educational level; and model 2 further adjusted for smoking status (never, ex-smoker, current-smoker), physical activity (MET-h/week), sedentary behavior (hours watching television/week), BMI (<25, 25–29.9, ≥30 kg/m2) and morbidity (cancer, diabetes, cardiovascular disease, osteomuscular disease, chronic respiratory disease). Models based on the SPPB score further adjusted for its baseline value. Statistical significance was set at two-sided P < 0.05. All analyses were performed using STATA version 13.0, (College Station, TX: Stata Corp LP). Results Among study participants, 48% lived in a walk-up building, 4% lacked heating and 6% felt frequently cold. The average (SD) number of poor conditions was 0.59 (0.64). Table 1 shows the main baseline characteristics of study participants by housing conditions. Individuals with ≥1 poor housing conditions were less educated and had a higher prevalence of obesity and osteomuscular disease. Table 1 Age- and sex- adjusted baseline characteristics of older adults by housing conditions N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 Continuous variables are presented as mean (standard deviations). SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living. Table 1 Age- and sex- adjusted baseline characteristics of older adults by housing conditions N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 N of poor housing conditions SPPB (N = 1602) Frailty (N = 1311) IADL disability (N = 1494) 0 (n = 767) ≥1 (n = 835) P-value 0 (n = 624) ≥1 (n = 687) P-value 0 (n = 723) ≥1 (n = 771) P-value Age, years 71.6 (0.2) 71.3 (0.2) 0.34 70.9 (0.2) 70.7 (0.2) 0.50 71.2 (0.2) 70.8 (0.2) 0.14 Men, % 50.9 47.0 0.12 51.0 48.4 0.35 51.8 48.4 0.19 Educational level, % <0.01 <0.01 <0.01  Primary or less 41.4 59.4 39.0 57.9 40.1 58.6  Seconday 29.3 23.8 29.8 23.5 30.0 23.9  University 29.3 16.8 31.1 18.6 30.0 17.5 Smoking status, % <0.05 0.05 0.06  Never smoker 56.6 63.0 56.4 63.1 55.6 62.1  Ex-smoker 34.4 28.0 34.6 27.9 34.8 28.6  Current smoker 9.0 8.9 9.0 9.0 9.6 9.2 Watching TV, h/week 19.1 (0.4) 19.4 (0.4) 0.60 18.6 19.0 0.42 18.9 19.0 0.86 Body mass index (kg/m2), % <0.01 <0.01 <0.01  <25 24.4 18.2 24.0 17.6 24.7 17.8  25–29.9 47.2 45.2 46.7 47.1 47.3 46.4  ≥30 28.4 36.5 29.2 35.2 28.0 35.8 Cancer, % 2.2 2.7 0.49 1.9 2.7 0.33 2.1 2.7 0.44 Diabetes, % 15.6 18.2 0.16 15.1 14.9 0.92 14.9 16.0 0.58 Cardiovascular disease, % 5.6 5.3 0.81 5.5 4.1 0.25 5.0 5.1 0.94 Osteomuscular disease, % 43.5 51.2 <0.01 43.4 50.0 <0.05 42.6 49.1 <0.05 Chronic respiratory disease, % 7.6 10.2 0.07 8.3 9.7 0.36 7.1 9.0 0.18 Continuous variables are presented as mean (standard deviations). SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living. During follow-up, 55 individuals (4.2%) developed incident frailty and 107 (7.2%) incident disabilities. Mean (SD) SPPB values at baseline and at follow-up were 8.5 (2.5) and 8.6 (2.4), respectively. After multivariate adjustment (model 2), participants who lived in homes with ≥1 poor condition showed similar SBBP scores at follow-up than those who lived in homes where the three services were present (beta: 0.01; 95% confidence interval [CI]: −0.20 to 0.21); however, higher risks of frailty (OR = 2.02; 95% CI: 1.09–3.75) were observed among those living in homes with ≥1 poor condition (Table 2). Table 2 Association between housing conditions and risk of limitations in physical function among older adults followed from 2008–2010 to 2015 in Spain SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living; CI, confidence interval; OR, odds ratio. Beta coefficients and their 95% confidence intervals were obtained from multivariate lineal regression models. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. Model 1 is adjusted for age, sex, educational level (≤primary, secondary, university). Linear regression models were also adjusted for the baseline SPPB score. Model 2 is adjusted as model 1 plus smoking status (never, ex-smoker, current-smoker), physical activity (MET-h/week), watching TV (h/week), BMI (<25, 25–29.9, ≥30 kg/m2) and comorbidities (cancer, diabetes, cardiovascular disease, osteomuscular disease, chronic respiratory disease). Statistically significant results are presented in bold. Table 2 Association between housing conditions and risk of limitations in physical function among older adults followed from 2008–2010 to 2015 in Spain SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB (n = 1602) Frailty (n = 1311) IADL (n = 1494) n Model 1 Beta (95% CI) Model 2 Beta (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Events/total Model 1 OR (95% CI) Model 2 OR (95% CI) Number of poor housing conditions 0 767 Ref. Ref. 19/624 Ref. Ref. 45/723 Ref. Ref. ≥1 835 −0.01 (−0.21;0.20) 0.01 (−0.20;0.21) 36/687 1.81 (1.00;3.26) 2.02 (1.00;3.75) 62/771 1.31 (0.86;2.00) 1.33 (0.87;2.05) Living in a walk-up building No 837 Ref. Ref. 24/687 Ref. Ref. 51/787 Ref. Ref. Yes 765 −0.07 (−0.27;0.14) −0.06 (−0.26;0.14) 31/624 1.50 (0.85;2.65) 1.65 (0.91;2.99) 56/707 1.24 (0.81;1.88) 1.26 (0.82;1.92) Lacking heating No 1533 Ref. Ref. 51/1256 Ref. Ref. 103/1431 Ref. Ref. Yes 69 0.23 (−0.27;0.73) 0.21 (−0.28;0.70) 4/55 1.89 (0.65;5.56) 1.88 (0.62;5.76) 4/63 0.85 (0.30;2.43) 0.85 (0.29;2.49) Frequently feeling cold No 1503 Ref. Ref. 48/1227 Ref. Ref. 98/1405 Ref. Ref. Yes 99 −0.10 (−0.51;0.32) −0.00 (−0.41;0.41) 7/84 2.25 (0.97;5.26) 2.22 (0.92;5.33) 9/89 1.49 (0.71;3.14) 1.38 (0.64;2.99) SPPB, Short Physical Performance Battery; IADL, instrumental activities of daily living; CI, confidence interval; OR, odds ratio. Beta coefficients and their 95% confidence intervals were obtained from multivariate lineal regression models. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. Model 1 is adjusted for age, sex, educational level (≤primary, secondary, university). Linear regression models were also adjusted for the baseline SPPB score. Model 2 is adjusted as model 1 plus smoking status (never, ex-smoker, current-smoker), physical activity (MET-h/week), watching TV (h/week), BMI (<25, 25–29.9, ≥30 kg/m2) and comorbidities (cancer, diabetes, cardiovascular disease, osteomuscular disease, chronic respiratory disease). Statistically significant results are presented in bold. Table 3 shows the association between housing conditions and risk of each frailty criterion among individuals who were robust, or pre-frail but free of the specific criterion of interest, at baseline. Older adults living in homes with ≥1 poor condition showed an increased risk of low physical activity (OR = 1.42; 95% CI: 1.00–2.03), mainly due to their homes lacking an elevator and adequate temperature control. Individuals living in homes with no heating also showed an increased risk of exhaustion (OR = 2.34; 95% CI: 1.00–5.48). Table 3 Association between housing conditions and risk of each criterion of frailty among Spanish older adults who were free of the criterion of interest at baseline Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. Table 3 Association between housing conditions and risk of each criterion of frailty among Spanish older adults who were free of the criterion of interest at baseline Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) Frailty criteria Weight loss (n = 1221) Exhaustion (n = 1201) Slow walking speed (n = 1156) Low physical activity (n = 1077) Weakness (n = 1123) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditions 0 46/591 Ref. 46/577 Ref. 45/553 Ref. 69/537 Ref. 57/521 Ref. ≥1 50/630 0.99 (0.64;1.53) 52/624 0.91 (0.58;1.41) 48/603 1.02 (0.65;1.60) 91/540 1.42 (1.00;2.03) 73/602 1.19 (0.81;1.75) Living in a walk-up building No 53/648 Ref. 54/629 Ref. 50/607 Ref. 80/590 Ref. 62/571 Ref. Yes 43/573 0.89 (0.58;1.38) 44/572 0.77 (0.50;1.21) 43/549 1.03 (0.65;1.61) 80/487 1.32 (0.93;1.88) 68/552 1.22 (0.83;1.80) Lacking heating No 103/1243 Ref. 90/1154 Ref. 93/115 Ref. 151/1036 Ref. 124/1083 Ref. Yes 4/54 0.86 (0.26;2.91) 8/47 2.34 (1.00;5.48) 0/41 – 9/41 1.55 (0.71;3.38) 6/40 1.48 (0.59;3.74) Feeling cold No 97/1213 Ref. 92/1135 Ref. 87/1079 Ref. 150/1014 Ref. 123/1052 Ref. Yes 10/84 1.22 (0.56;2.66) 6/66 1.07 (0.43;2.64) 6/77 1.04 (0.42;2.56) 10/63 1.03 (0.51;2.10) 7/71 0.78 (0.34;1.77) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. Results from Table 4 show that the presence of ≥1 poor housing condition was associated with an increased risk of transportation disability (OR = 3.50; 95% CI: 1.38–8.88) among older adults who were free from IADL disabilities at baseline. In particular, those frequently feeling cold showed the highest risks of transportation disability (OR = 3.31; 95% CI: 1.07–10.21). Table 4 Association between housing conditions and risk of each disability in instrumental activities of daily living (IADL) among Spanish older adults free of IADL disabilities at baseline Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. aMeal preparation, housework and laundry are excluded in men. bThe item ‘ability to use the telephone’ has been excluded from the table because only one individual had limitations in this item. Table 4 Association between housing conditions and risk of each disability in instrumental activities of daily living (IADL) among Spanish older adults free of IADL disabilities at baseline Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) Disabilities in instrumental activities of daily living Transportation (n = 1267) Shopping (n = 1301) Taking medications (n = 1301) Managing finances (n = 1301) Houseworka (n = 649) Meal preparationa (n = 649) Laundrya (n = 649) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Events/total OR (95% CI) Number of poor housing conditionsb 0 7/617 Ref. 32/617 Ref. 12/617 Ref. 2/617 Ref. 4/299 1.00 11/299 1.00 3/299 1.00 ≥ 1 22/684 3.50 (1.38; 8.88) 44/684 1.25 (0.75;2.07) 11/684 0.81 (0.34;1.93) 4/684 1.66 (0.20;14.19) 4/350 1.32 (0.20;8.67) 8/350 0.50 (0.18;1.38) 10/350 2.70 (0.67;11.04) Living in a walk-up building No 11/677 Ref. 36/677 Ref. 13/677 Ref. 3/677 Ref. 5/326 Ref. 12/326 Ref. 4/326 Ref. Yes 18/624 2.07 (0.93;4.76) 40/624 1.23 (0.75;2.03) 10/1301 0.81 (0.33;1.95) 3/624 1.11 (0.13;9.13) 3/323 1.20 (0.18;8.16) 7/323 0.47 (0.16;1.33) 9/323 2.52 (0.65;9.82) Lacking heating No 27/1243 Ref. 74/1243 Ref. 23/1243 Ref. 6/1243 Ref. 8/619 Ref. 19/619 Ref. 12/619 Ref. Yes 2/58 2.11 (0.43;10.4) 2/58 0.51 (0.12;2.24) 0/58 – 0/58 – 0/30 – 0/30 – 1/30 3.20 (0.32;32.4) Frequently feeling cold No 24/1219 Ref. 4/1219 Ref. 20/1219 Ref. 4/1219 Ref. 7/605 Ref. 18/605 Ref. 11/605 Ref. Yes 5/82 3.31 (1.07;10.2) 2/82 5.12 (0.37;70.9) 3/82 1.93 (0.52;7.21) 2/82 5.12 (0.37;70.9) 1/44 1.36 (0.03;64.1) 1/44 0.76 (0.09;6.59) 2/44 2.24 (0.32;15.7) CI, confidence interval; OR, odds ratio. Odds ratios and their 95% confidence intervals were obtained from multivariate logistic regression models. All models adjusted as model 2 in Table 2. Statistically significant results are presented in bold. aMeal preparation, housework and laundry are excluded in men. bThe item ‘ability to use the telephone’ has been excluded from the table because only one individual had limitations in this item. As sensitivity analyses, we evaluated the risk of presenting an SPPB score over 9 and analyzed the IADL scale as a continuous variable, and we obtained similar results (please see Supplementary Table S1). Discussion Main finding of this study Results add to our previous cross-sectional observations showing that older adults living in poor housing are at increased risk of frailty.12 However, they do not support a prospective relationship between living conditions and risk of poor lower extremity performance or IADL disability. What is already known on this topic Ageing in place is considered to support older adults to live independently. However, only a few studies have evaluated whether certain home features may be associated with the risk of functional limitations in community-dwelling older adults. To our knowledge, this is the first study to investigate the association between poor housing conditions and risk of frailty or IADL disability, and the first to prospectively evaluate the association between home characteristics and reduced SPPB scores. Living in walk-up apartments may prevent older adults from going outdoors, an activity that has been prospectively associated with functional and intellectual health benefits among this subpopulation.22–25 Moreover, there is evidence in the literature that homebound older adults are at increased risk of sedentariness,26 nutritional deficiencies27,28 and depression,29 all of which are known risk factors of frailty and disability.17,30–32 There is also strong evidence that cold homes have a harmful effect on health, especially among older people, who have reduced thermoregulatory control and thermal discrimination.33,34 However, previous studies focusing on the effects of cold temperatures on functional outcomes are scarce and lack follow-up evaluations.6,12,35,36 One of the existing cross-sectional studies, with 88 women randomly exposed to 15 and 25°C climate chambers, showed decreased gait speed and worse extremity performance with lower room temperatures.35 Another, showed worse handgrip strength values in UK participants who resided in homes with measured temperatures <18°C when compared to their counterparts.6 Finally, in our own cross-sectional study we found that ‘lacking heating’ and, to a less extent, ‘feeling frequently cold’ were associated with worse extremity performance and higher prevalence of frailty and some of its components, but not with the prevalence of IADL disability.12 Although some of the present analyses failed to find significant outcome differences, they suggest that ‘feeling frequently cold’ may be a risk factor of frailty and transportation disability, while support our previous findings that lacking heating is associated with the risk of developing exhaustion. What this study adds In our study, participants with ≥1 poor conditions had a 0.8% higher absolute risk of frailty, a 0.9% higher absolute risk of transportation disability, and a 1.34% higher absolute risk of low physical activity per year of follow-up. Given the high prevalence of poor housing, with 52% of the study cohort presenting ≥1 poor condition, these findings have substantial public health relevance. Limitations of this study Among the potential limitations of this study is the low prevalence of exposure to some of the exposures of interest (i.e. lack of piped hot water at home), the lack of temperature measurements, as well as the low incidence of some of the studied outcomes (i.e. IADL disability), all of which could have prevented us from detecting some existing associations. Despite this, we did observe a strong and clinically relevant association between housing conditions and frailty and some of its components. As an additional disadvantage, our results cannot be extrapolated to older populations living in countries with major differences in climate or urban planning, as well as to institutionalized populations. Moreover, as in other cohorts with older adults, the sample size decreased over time because of a substantial number of deaths and losses to follow-up. Given that individuals lost to follow-up showed a higher prevalence of morbidities and functional limitations at baseline, participants who remained in poor housing conditions may represent a ‘survivor cohort’ of people who are fit enough to remain in their usual homes. The main strengths of this study include its longitudinal design, the use of validated measures of physical function in older adults, and the adjustment for good number of covariates, which reduces the probability of residual confounding. Conclusion Our results support the role of poor housing conditions in the development of frailty. Prevention programs targeting functional limitations and disability in older people should ensure that older adults live in homes that are accessible to the street and have adequate temperature systems. Funding This work was supported by a grant from CIBERESP, FIS grants 16/609 and 13/0288 (Instituto de Salud Carlos III, State Secretary of R+D+I and FEDER/FSE), the FRAILOMIC Initiative (European Union FP7-HEALTH-2012-Proposal no. 305483-2) and the ATHLOS project (European project H2020- Project ID: 635316). The funding agencies had no role in study design, data analysis, interpretation of results, article preparation or in the decision to submit this article for publication. Conflict of interest We have no conflicts of interest to declare. References 1 Cooper R , Kuh D , Cooper C et al. . Objective measures of physical capability and subsequent health: a systematic review . Age Ageing 2011 ; 40 : 14 – 23 . Google Scholar Crossref Search ADS PubMed 2 Guralnik JM , Ferrucci L , Simonsick EM et al. . Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability . N Engl J Med 1995 ; 332 : 556 – 61 . Google Scholar Crossref Search ADS PubMed 3 Legrand D , Vaes B , Mathei C et al. . Muscle strength and physical performance as predictors of mortality, hospitalization, and disability in the oldest old . J Am Geriatr Soc 2014 ; 62 : 1030 – 8 . Google Scholar Crossref Search ADS PubMed 4 World Health Organization . World Report on Ageing and Health. http://www.who.int/ageing/events/world-report-2015-launch/en. (20 July 2017 , date last accessed). 5 Webb E , Blane D , de Vries R . Housing and respiratory health at older ages . J Epidemiol Community Health 2013 ; 67 : 280 – 5 . Google Scholar Crossref Search ADS PubMed 6 Shiue I . Cold homes are associated with poor biomarkers and less blood pressure check-up: English Longitudinal Study of Ageing, 2012-2013 . 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Google Scholar Crossref Search ADS PubMed 23 Jacobs JM , Cohen A , Hammerman-Rozenberg R et al. . Going outdoors daily predicts long-term functional and health benefits among ambulatory older people . J Aging Health 2008 ; 20 : 259 – 72 . Google Scholar Crossref Search ADS PubMed 24 Simonsick EM , Guralnik JM , Volpato S et al. . Just get out the door! Importance of walking outside the home for maintaining mobility: findings from the women’s health and aging study . J Am Geriatr Soc 2005 ; 53 : 198 – 203 . Google Scholar Crossref Search ADS PubMed 25 Harada K , Lee S , Lee S et al. . Objectively-measured outdoor time and physical and psychological function among older adults . Geriatr Gerontol Int 2016 ; 17 : 1455 – 62 . Google Scholar PubMed 26 Leask CF , Harvey JA , Skelton DA et al. . Exploring the context of sedentary behaviour in older adults (what, where, why, when and with whom) . Eur Rev Aging Phys Act 2015 ; 12 : 4 . 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Google Scholar Crossref Search ADS PubMed 35 Lindemann U , Oksa J , Skelton DA et al. . Effect of cold indoor environment on physical performance of older women living in the community . Age Ageing 2014 ; 43 : 571 – 5 . Google Scholar Crossref Search ADS PubMed 36 Greaney JL , Stanhewicz AE , Kenney WL et al. . Muscle sympathetic nerve activity during cold stress and isometric exercise in healthy older adults . J Appl Physiol 1985 ; 2014 ( 117 ): 648 – 57 . © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Journal of Public HealthOxford University Press

Published: Sep 1, 2018

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