Association of balance impairment with risk of incident cardiovascular diseases among older adults

doi:10.21203/rs.3.rs-2616619/v1

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Research Article

Association of balance impairment with risk of incident cardiovascular diseases among older adults

https://doi.org/10.21203/rs.3.rs-2616619/v1

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Journal Publication

published 24 Oct, 2023

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Background: Rapid decline in balance is a hallmark of aging, elevating the risk of falls and other age-related geriatric illnesses among older adults.

Objective: Our aim was to assess whether impairment in balance function is associated with the risk of incident CVD in older adults.

Design: Retrospective cohort analysis

Participants: A total of 129,024 participants who had undergone health screening between 2002 and 2009 were derived the National Health Insurance Service-Senior.

Main Measures: Balance impairment was evaluated using the open-eyes one-leg standing (OLS) test. The association between balance impairment and incident CVD was analyzed using the Cox proportional hazards regression model. All participants were followed up with until either the date of the first incident of CVD, death, or 31 December 2019.

Key Results: Those with abnormal balance function (<10 seconds in OLS test) had a higher risk of CVD (adjusted hazard ratio [aHR] 1.23, CI 1.16-1.31). The association was significant in both the obese and the non-obese, but it seemed to be more pronounced in the latter. Results were supported by sensitivity analyses that did not include cases of CVD development in the first 1, 2, or 3 years and that used a different criterion to define balance dysfunction (<9 seconds in OLS test).

Conclusions: Older adults with balance impairment were found to have an increased risk of incident CVD. Patients with impaired balance function may be a high-risk population who require preventive managements against CVD.

postural balance

one-leg standing

public health

cardiovascular diseases

coronary heart disease

stroke

Despite a gradual decline in cardiovascular diseases (CVD) prevalence in developed countries due to therapeutic advances and preventative efforts, CVD remains a significant burden in an aging population ¹. CVD not only causes progressive dysfunction in older adults, but also remain as the leading cause of death in this age group ². Evidence-based clinical practice guidelines are frequently used and generally followed by practitioners in the field of cardiovascular care ³. Although the identification and implementation of CVD risk factors according to these guidelines has greatly benefited the general population, such recommendations may be less reliable in older adults, as clinical complexities associated with aging are more likely to confound standard precepts ⁴.

Along with aging, the gradual biologic changes associated with longevity are favorable to the onset of CVD and other age-related geriatric conditions such as frailty, sarcopenia, and falls ^2,5. For older adults, mobility impairment is associated with a lower quality of life, an increased risk of institutionalization, and premature death ⁶. While good mobility necessitates the ability to maintain one's balance while engaging in a variety of activities ⁷, aging can cause changes that lead to dysfunctional balancing, independently of illness or medication ^8,9. Maintaining balance requires comprehensive contributions from the vestibular, visual, and proprioceptive systems ¹⁰. Unlike aerobic fitness, muscle strength, or flexibility, balance tends to be adequately maintained until the 60s, when it begins to decline rapidly ⁶.

Recently, a significant inverse association between balance function and CVD-related mortality risk was reported ⁷. Similarly, a link between locomotor dysfunction and an increased risk of CVD has been found in the adults of mean age 66 ¹¹. Despite ongoing efforts to determine the influence of mobility dysfunction on the CVD risk, the presence of balance dysfunction is likely underestimated in clinical practice, and most investigations are focused on the mortality risk of CVD ^6,12. Hence, there remains large-scale study to clarify the association between balance impairment and the risk of incident CVD in older adults. Thus, using nationally representative data of Korean population, this study sought to determine whether balance impairment increases the risk of CVD in older adults.

Study Population

Data for this retrospective cohort study were drawn from the Korea National Health Insurance Service (NHIS)-Senior Cohort. The elucidations of the cohort are described in detail elsewhere ¹³. The NHIS provides compulsory insurance services regarding all aspects of medical healthcare for Korean citizens. Information on lifestyle behaviors, serological characteristics, and anthropometric measurements have been collected by the NHIS alongside demographic information, drug prescription records, treatment notes, and the results of health screening examinations.

We analyzed data from 159,174 people who took a balance function test as part of a health screening between 2009 and 2017. First, we filtered out the people who already had a CVD diagnosis before the follow-up began (n = 29,631), as well as those with missing information for covariates (n = 519). Finally, a total of 129,024 people aged 66 without a known history of CVD were included in the final analytic cohort (Fig. 1). This study was conducted in accordance with STROBE guidelines ¹⁴. This study was approved as exempt from Institutional Review Board of Jeju National University Hospital (approval No. JNUH IRB File No.2021-07-008). Since the database was made anonymous in accordance with strict confidentiality guidelines, it was unnecessary to obtain informed consents.

Follow-up for CVD

Starting on January 1, 2009, all participants were followed up until either CVD diagnosis, death, or 31 December, 2019. The presence of CVD was determined by whether or not a participant had been hospitalized for two or more days due to coronary heart disease (CHD) (International Classification of Diseases Tenth Revision [ICD-10] codes, I20-I25) or stroke (ICD-10 codes, I60-I69) according to the American Heart Association guidelines ¹⁵. Several prior research have relied on the NHIS's operational definition of CVD, and is considered accurate ¹⁶.

Key variables

Potential confounding factors for the adjusted analyses included age (continuous; years), sex (categorical; men and women), insurance premium as a proxy for household income (categorical; upper half and lower half), body mass index (BMI; continuous; kg/m²), type 2 diabetes (DM; categorical; yes and no), hypertension (categorical; yes and no), dyslipidemia (categorical; yes and no), smoking (categorical; never, past, and current), alcohol consumption (categorical; yes and no), moderate-to-vigorous physical activity (MVPA; categorical; 0, 1–2, 3–4, and ≥ 5 times/week), and Charlson comorbidity index (CCI; categorical; 0, 1–2, and ≥ 3).

DM, hypertension, and dyslipidemia were defined using the ICD-10 codes (DM, E10 to E14; hypertension, I10; dyslipidemia, E78) and prescription of antidiabetic, antihypertensive, and antidyslipidemic drugs. We calculated the CCI as elucidated in a previous study ¹⁷.

Statistical analysis

To assess the association between balance impairment and incident CVD, we used the Cox proportional hazards regression. The adjusted hazard ratio (aHR) and 95% confidence interval (CI) were calculated after adjusting for age and sex solely in the first adjustment model. In addition, we included age, sex, household income, BMI, DM, hypertension, dyslipidemia, alcohol consumption, smoking, MVPA, and CCI as adjustment variables in the final adjustment model.

We used the open-eyes OLS test to evaluate the balance function, which is considered high reliable and predictable for certain outcomes, such as falls and incident disability ¹⁸. Normal, cautious, and abnormal balance functions were stratified according to ≥ 20 seconds (s), between 10s to 19s, and < 10s from the OLS test. The incidence of CVD was calculated after dividing events by 1,000 person-years (PY). We carried out sensitivity analysis to ensure that the primary results were not influenced by other potential reasons. To support the primary results, on-developing CVD cases at the time of follow-up were excluded by excluding CVD cases that occurred within 1, 2, or 3 years since the first date of follow-up.

Stratified analyses were performed to testify potential interactions among balance function, CVD, and stratification variables. The restricted cubic splines (RCS) were drawn by setting 3 knots at the 5th, 50th, and 95th percentiles to visualize the association between continuous OLS senconds and incident CVD. A two-sided P < 0.05 was considered statistically significant. Statistical analyses were performed using R software version 3.3.3 (R foundation for Statistical Computing, Vienna, Austria) and SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

Participant characteristics

Descriptive baseline characteristics of the analytic cohort is presented in Table 1. There were 88,000, 26,186, and 14,838 older adults with normal, cautious, and impaired balance functions. Those with balance dysfunction were more tended to be women sex with lower household income, DM, hypertension, dyslipidemia, comorbidities, and hearing impairment who have higher BMI, higher blood pressures, higher fasting serum glucose, and lower frequency of MVPA.

Table 1

Baseline characteristics of the participants who underwent health screening according to the balance function
Characteristic	Normal, ≥ 20 s (n = 88,000)	Cautious, 10–19 s (n = 26,186)	Abnormal, < 10 s (n = 14,838)	P value
Age, years	66 (66–66)	66 (66–66)	66 (66–66)	0.282
Sex, n (%)				< 0.001
Men	43,663 (49.6)	10,157 (38.8)	4,930 (33.2)
Women	44,337 (50.4)	16,029 (61.2)	9,908 (66.8)
Household income, n (%)				< 0.001
Upper half	52,212 (59.3)	15,181 (58.0)	8,286 (55.8)
Lower half	35,788 (40.7)	11,005 (42.0)	6,552 (44.2)
Body mass index, kg/m²	23.9 (22.1–25.8)	24.3 (22.5–26.4)	24.7 (22.6–27.0)	< 0.001
Waist circumference, cm	82 (77–88)	83 (78–89)	84 (79–90)	< 0.001
Systolic blood pressure, mmHg	128 (118–136)	130 (119–138)	130 (120–139)	< 0.001
Diastolic blood pressure, mmHg	78 (70–82)	79 (70–83)	79 (70–84)	< 0.001
Fasting serum glucose, mg/dL	98 (90–109)	99 (90–111)	99 (91–114)	< 0.001
Total cholesterol, mg/dL	195 (171–221)	196 (171–223)	195 (169–223)	0.003
Smoking status, n (%)				< 0.001
Never	58,952 (67.0)	19,326 (73.8)	11,265 (75.9)
Previous	17,861 (20.3)	3,755 (14.3)	1,863 (12.6)
Current	11,187 (12.7)	3,105 (11.9)	1,710 (11.5)
Alcohol consumption, n (%)				< 0.001
Yes	27,486 (31.2)	6,981 (26.7)	3,631 (24.5)
No	60,514 (68.8)	19,205 (73.3)	11,207 (75.5)
MVPA, n (%)				< 0.001
0 time/week	43,428 (49.4)	14,550 (55.6)	9,170 (61.8)
1–2 time/week	10,376 (11.8)	2,806 (10.7)	1,508 (10.2)
3–4 time/week	11,132 (12.7)	2,838 (10.8)	1,380 (9.3)
≥5 time/week	23,064 (26.2)	5,992 (22.9)	2,780 (18.7)
Hypertension, n (%)	28,209 (32.1)	9,571 (36.6)	5,953 (40.1)	< 0.001
Diabetes, n (%)	8,662 (9.8)	3,222 (12.3)	2,316 (15.6)	< 0.001
Dyslipidemia, n (%)	13,866 (15.8)	4,546 (17.4)	2,762 (18.6)	< 0.001
Charlson comorbidity index, n (%)				< 0.001
0	15,120 (17.2)	3,983 (15.2)	2,037 (13.7)
1	20,326 (23.1)	5,569 (21.3)	2,954 (19.9)
≥2	52,554 (59.7)	16,634 (63.5)	9,847 (66.4)
Hearing impairment, n (%)				< 0.001
Yes	994 (1.1)	369 (1.4)	276 (1.9)
No	87,006 (98.9)	25,817 (98.6)	14,562 (98.1)
Data are mean (standard deviation) unless indicated otherwise.

Association between balance impairment and risk of CVD

A total of 9,587 cases of new onset CVD were identified during the 737,500 person-years of follow-up. There was a strong association between lower balance function and an increased risk of CVD (Table 2; P for trend < 0.001). Compared with participants with normal balance function, those with impaired balance function had an elevated risk of CVD (aHR, 1.23; 95% CI, 1.16–1.31). Both obese (aHR, 1.17; 95% CI, 1.07–1.28) and non-obese groups (aHR, 1.30; 95% CI, 1.20–1.41) showed similar results. In addition, the associations of balance impairment with CHD (aHR, 1.23; 95% CI, 1.16–1.31) and stroke (aHR, 1.33; 95% CI, 1.23–1.43) were significant (Table 3). Also, in line with the main findings of this study, the Kaplan-Meier cumulative risks for overall CVD were higher in the abnormal balance group than the normal balance function group (Fig. 2). Additionally, we identified the risk-increasing effect on CVD by shorter OLS in a continuous manner (Fig. 3).

Table 2

Association of balance function with incident cardiovascular disease
	Normal (≥ 20 s)	Cautious (10–19 s)	Abnormal (< 10 s)	P for trend
Overall participant, n	88,000	26,186	14,838
Event (%)	6,054 (6.9)	2,190 (8.4)	1,343 (9.1)
Person-year	493,593	156,745	87,162
Incidence/1,000 person-year	12.3	14.0	15.4
HR (95% CI)	1.00 (Reference)	1.13 (1.08–1.19)	1.25 (1.18–1.33)	< 0.001
aHR (95% CI)^a	1.00 (Reference)	1.19 (1.13–1.25)	1.34 (1.27–1.43)	< 0.001
aHR (95% CI)^b	1.00 (Reference)	1.14 (1.08–1.19)	1.23 (1.16–1.31)	< 0.001
Obese participant, n	31,538	10,971	7,010
Event (%)	2,291 (7.3)	954 (8.7)	608 (8.7)
Person-year	174,824	64,792	40,868
Incidence/1,000 person-year	13.1	14.7	14.9
HR (95% CI)	1.00 (Reference)	1.12 (1.04–1.21)	1.13 (1.04–1.24)	0.002
aHR (95% CI)^a	1.00 (Reference)	1.18 (1.10–1.28)	1.24 (1.13–1.36)	< 0.001
aHR (95% CI)^b	1.00 (Reference)	1.15 (1.07–1.24)	1.17 (1.07–1.28)	< 0.001
Non-obese participant, n	56,462	15,215	7,828
Event (%)	3,763 (6.7)	1,236 (8.1)	735 (9.4)
Person-year	318,769	91,952	46,294
Incidence/1,000 person-year	11.8	13.4	15.9
HR (95% CI)	1.00 (Reference)	1.13 (1.06–1.21)	1.34 (1.24–1.45)	< 0.001
aHR (95% CI)^a	1.00 (Reference)	1.17 (1.10–1.25)	1.41 (1.30–1.53)	< 0.001
aHR (95% CI)^b	1.00 (Reference)	1.13 (1.06–1.20)	1.30 (1.20–1.41)	< 0.001
HR calculated using Cox proportional hazards regression.
^aAdjusted for age and sex.
^bAdjusted for age, sex, household income, hypertension, diabetes, dyslipidemia, smoking, alcohol consumption, moderate-to-vigorous physical activity, and Charlson comorbidity index.
Acronym: HR, hazard ratio; CI, confidence interval; aHR, adjusted hazard ratio.

Table 3

Association of balance function with incident coronary heart disease and stroke
	Normal (≥ 20 s)	Cautious (10–19 s)	Abnormal (< 10 s)	P for trend
Coronary heart disease
HR (95% CI)	1.00 (Reference)	1.13 (1.08–1.19)	1.25 (1.18–1.33)	< 0.001
aHR (95% CI)^a	1.00 (Reference)	1.19 (1.13–1.25)	1.34 (1.27–1.43)	< 0.001
aHR (95% CI)^b	1.00 (Reference)	1.14 (1.08–1.19)	1.23 (1.16–1.31)	< 0.001
Stroke
HR (95% CI)	1.00 (Reference)	1.17 (1.10–1.24)	1.36 (1.26–1.46)	< 0.001
aHR (95% CI)^a	1.00 (Reference)	1.20 (1.13–1.28)	1.42 (1.32–1.53)	< 0.001
aHR (95% CI)^b	1.00 (Reference)	1.16 (1.09–1.24)	1.33 (1.23–1.43)	< 0.001
HR calculated using Cox proportional hazards regression.
^aAdjusted for age and sex.
^bAdjusted for age, sex, household income, hypertension, diabetes, dyslipidemia, smoking, alcohol consumption, moderate-to-vigorous physical activity, and Charlson comorbidity index.
Acronym: HR, hazard ratio; CI, confidence interval; aHR, adjusted hazard ratio.

Primary results were validated through sensitivity analyses that were performed after excluding CVD events within 1, 2, and 3 years since the beginning of the follow-up (Supplementary Table 1, Supplementary Table 2).

Subgroup analyses on the association of balance functions with risk of incident CVD is shown in Supplementary Table 3. Older adults were stratified according to sex, household income, DM, hypertension, dyslipidemia, MVPA, and hearing impairment. A higher risk of CVD was observed in the impaired balance function groups except for those with hearing impairment, and we found no significant interactions.

The association between OLS test and the risk of CVD was noted in this study. Participants with impaired balance function had a 1.23-fold increased CVD risk compared to participants with normal balance function after adjusting for potential confounders. Despite older adults with impaired balance function were more likely to develop both CHD and stroke, the balance function-dependent risk was stronger for stroke. These findings may pave a way for further investigation into the relationship between balance function and the risk of CVD, providing supports for effective healthcare initiatives.

Impaired balance contributes to a wide range of negative health outcomes ¹⁹. However, there is limited evidence regarding balance function and the onset of CVD. A recent study involving 5,816 US adults aged over 40 found that those with a balance dysfunction had a 65% higher CVD mortality compared to those with normal balance function, as measured by the modified Romberg standing balance test ⁷. In a Japanese cohort study with 1,085 elderly participants aged 65 to 89 years who received the OLS test, balance impairment was associated with a 91% increased risk of CVD-related death ²⁰. Another recent Turkish study involving 44 older adults with a mean age of 59 found that balance function was reduced in patients with chronic heart failure as measured by the Activity-Specific Balance Confidence Scale and the Mini-Balance Evaluation Systems Test ¹⁹. The present study found a significant association of balance disorder and incident CVD that, to our knowledge, was previously not reported among older adults.

A behavior-related mechanism may explain the association between balance function and incident CVD. The prevalence of vestibular dysfunction rise sharply with aging, and this can affect the balance function of individuals ²¹. People who experienced symptoms such as dizziness as a result of vestibular impairment were 12 times more likely to fall than those with normal vestibular function ²¹. Falls, primarily caused by poor balance can result in long-term immobility and a sedentary lifestyle ²². Certain sedentary behaviors have been associated with an increased risk of CVD ^23,24. Furthermore, fear of falling causes older adults to be less active and spend more time sitting than they should, increasing their CVD risk ²³. In a biological manner, the activity of the lipoprotein lipase in the postural muscles of rats has been shown to decrease when they are forced to remain immobile ²⁵. Low levels of lipoprotein lipase is associate with reduced triacylglycerol uptake, lower plasma HDL cholesterol levels, and higher risk of CVD ²⁵. In addition, lipid abnormalities are related to an increased risk of atherosclerosis or myocardial infarction in patients with vertigo ²⁶.

Another possible explanation is that frailty caused by balance impairment increases the risk of CVD. Despite the fact that a variety of definitions for quantifying frailty status have been proposed ²⁰, poor physical performance is widely recognized as a hallmark of frailty. Perhaps the increased risk of CVD in frail elderly people is due to their susceptibility to psychological and physiological stresses ²⁰. Although there is limited evidence to support frailty to a risk factor for CVD incidence, it has been associated to both clinical and underlying CVD ²⁷. To better inform clinical practice, further investigation to clarify pathways connecting balance disorder and CVD risk is warranted.

To date, assessing the balance of older adults has not been standard practice in clinical examinations. This could be attributed to a lack of consensus on how to measure balance, as well as a lack of information linking balance test results to clinical outcomes other than falls ⁶. Therefore, the findings of this study may be useful for screening individuals at risk of CVD and suggesting prevention and intervention initiatives to lower the risk of CVD ²⁸. However, the following limitations should be considered when interpreting this study results. First, this study is not exempt to the issue of reverse causality because of its retrospective nature. Future prospective studies would be warranted to determine the causal relationship between balance impairment and the risk of CVD. Second, the OLS test was the only parameter used to assess balance performance in this study. Although OLS has been one of the standard methods for evaluating postural stability for several decades, due to its ease of use and short test time ^29,30, additional studies based on other metrics for measuring balance function may be required to generalize our findings.

Balance impairment was associated with an increased risk of incident CVD in this nationally representative cohort study of Korean older adults. As the prevalence of balance impairments rises with aging, assessing balance function in clinical and research settings may be considered to better estimate the risk of CVD. Such assessment may allow better referrals to specialists for individual-level healthcare plans.

Ethical Approval

This study was approved as exempt from Institutional Review Board of Jeju National University Hospital (approval No. JNUH IRB File No.2021-07-008).

Authors' contributions

Conceptualization: Michelle J. Suh, Yun Hwan Oh; Formal analysis: Hye Jun Kim; Investigation: Seogsong Jeong; Writing-original draft: Hye Jun Kim; Writing-review and editing: Michelle J. Suh, Yun Hwan Oh.

Funders: none

Prior presentations: Not presented before

Conflict of interest: None declared.

Data availability statement: The datasets generated during and / or analysed during the current study are available from the corresponding author on reasonable request.

Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics—2021 update: a report from the American Heart Association. Circulation. 2021;143(8):e254-e743.
O’Neill DE, Forman DE. Cardiovascular care of older adults. bmj. 2021;374
Jeong SM, Choi S, Kim K, et al. Effect of change in total cholesterol levels on cardiovascular disease among young adults. Journal of the American Heart Association. 2018;7(12):e008819.
Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528.
Wright RM, Sloane R, Pieper CF, et al. Underuse of indicated medications among physically frail older US veterans at the time of hospital discharge: results of a cross-sectional analysis of data from the Geriatric Evaluation and Management Drug Study. The American journal of geriatric pharmacotherapy. 2009;7(5):271-280.
Araujo CG, e Silva CGdS, Laukkanen JA, et al. Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals. British Journal of Sports Medicine. 2022;
Cao C, Cade WT, Li S, McMillan J, Friedenreich C, Yang L. Association of balance function with all-cause and cause-specific mortality among US adults. JAMA Otolaryngology–Head & Neck Surgery. 2021;147(5):460-468.
Dutil M, Handrigan GA, Corbeil P, et al. The impact of obesity on balance control in community-dwelling older women. Age. 2013;35(3):883-890.
Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged≥ 65 years—United States, 2014. Morbidity and Mortality Weekly Report. 2016;65(37):993-998.
Kahiel Z, Grant A, Aubin M-J, Buhrmann R, Kergoat M-J, Freeman EE. Vision, eye disease, and the onset of balance problems: The Canadian longitudinal study on aging. American Journal of Ophthalmology. 2021;231:170-178.
Otani K, Takegami M, Fukumori N, et al. Locomotor dysfunction and risk of cardiovascular disease, quality of life, and medical costs: design of the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS) and baseline characteristics of the study population. Journal of Orthopaedic Science. 2012;17(3):261-271.
Denfeld QE, Turrise S, MacLaughlin EJ, et al. Preventing and managing falls in adults with cardiovascular disease: a scientific statement from the American Heart Association. Circulation: Cardiovascular Quality and Outcomes. 2022:10.1161/HCQ. 0000000000000108.
Kim YI, Kim Y-Y, Yoon JL, et al. Cohort Profile: National health insurance service-senior (NHIS-senior) cohort in Korea. BMJ open. 2019;9(7):e024344.
Von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Annals of internal medicine. 2007;147(8):573-577.
Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. circulation. 2016;133(4):e38-e360.
Son JS, Choi S, Kim K, et al. Association of blood pressure classification in Korean young adults according to the 2017 American College of Cardiology/American Heart Association guidelines with subsequent cardiovascular disease events. Jama. 2018;320(17):1783-1792.
Sundararajan V, Henderson T, Perry C, Muggivan A, Quan H, Ghali WA. New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. Journal of clinical epidemiology. 2004;57(12):1288-1294.
Vafaei A, Aubin MJ, Buhrmann R, Kergoat MJ, Aljied R, Freeman EE. Interaction between visual acuity and peripheral vascular disease with balance. Journal of the American Geriatrics Society. 2018;66(10):1934-1939.
Ozcan EB, Saglam M, Vardar-Yagli N, et al. Impaired Balance and Gait Characteristics in Patients With Chronic Heart Failure. Heart, Lung and Circulation. 2022;31(6):832-840.
Nofuji Y, Shinkai S, Taniguchi Y, et al. Associations of walking speed, grip strength, and standing balance with total and cause-specific mortality in a general population of Japanese elders. Journal of the American Medical Directors Association. 2016;17(2):184. e1-184. e7.
Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004. Archives of internal medicine. 2009;169(10):938-944.
Bruce DG, Devine A, Prince RL. Recreational physical activity levels in healthy older women: the importance of fear of falling. Journal of the American Geriatrics Society. 2002;50(1):84-89.
Yang L, Cao C, Kantor ED, et al. Trends in sedentary behavior among the US population, 2001-2016. Jama. 2019;321(16):1587-1597.
Wilmot EG, Edwardson CL, Achana FA, et al. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis. Diabetologia. 2012;55(11):2895-2905.
Hamilton MT, Healy GN, Dunstan DW, Zderic TW, Owen N. Too little exercise and too much sitting: inactivity physiology and the need for new recommendations on sedentary behavior. Current cardiovascular risk reports. 2008;2(4):292-298.
Santos M, Bittar R. Vertigo and metabolic disorders. Int Tinnitus J. 2012;17(1):16-20.
Newman AB, Gottdiener JS, McBurnie MA, et al. Associations of subclinical cardiovascular disease with frailty. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001;56(3):M158-M166.
D'Silva LJ, Lin J, Staecker H, Whitney SL, Kluding PM. Impact of diabetic complications on balance and falls: contribution of the vestibular system. Physical therapy. 2016;96(3):400-409.
Springer BA, Marin R, Cyhan T, Roberts H, Gill NW. Normative values for the unipedal stance test with eyes open and closed. Journal of geriatric physical therapy. 2007;30(1):8-15.
Narozny W, Tretiakow D, Skorek A. Investigations of Malfunctions of the Vestibular System. JAMA Otolaryngology–Head & Neck Surgery. 2021;147(8):774-775.

No competing interests reported.

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Association of balance impairment with risk of incident cardiovascular diseases among older adults

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Follow-up for CVD

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Participant characteristics

Association between balance impairment and risk of CVD

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