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Midlife job profiles and disabilities in later life: a 28-year follow-up of municipal employees in Finland.

https://arctichealth.org/en/permalink/ahliterature284220
Source
Int Arch Occup Environ Health. 2016 Aug;89(6):997-1007
Publication Type
Article
Date
Aug-2016
Author
K C Prakash
Subas Neupane
Päivi Leino-Arjas
Mikaela B von Bonsdorff
Taina Rantanen
Monika E von Bonsdorff
Jorma Seitsamo
Juhani Ilmarinen
Clas-Håkan Nygård
Source
Int Arch Occup Environ Health. 2016 Aug;89(6):997-1007
Date
Aug-2016
Language
English
Publication Type
Article
Keywords
Activities of Daily Living
Adult
Age Factors
Cluster analysis
Disability Evaluation
Female
Finland - epidemiology
Follow-Up Studies
Health status
Humans
Life Style
Local Government
Male
Middle Aged
Occupational Diseases - epidemiology - etiology
Occupations - statistics & numerical data
Prospective Studies
Regression Analysis
Risk factors
Socioeconomic Factors
Surveys and Questionnaires
Work
Abstract
Occupations during adult life may have long-term effects and subsequently increase the risk of disability in old age. We investigated the associations between job profile groups in midlife and disability in old age for women and men.
This prospective 28-year follow-up study (1981-2009) examined 2998 municipal employees (1892 women and 1106 men) aged 44-58?years at baseline. A detailed analysis of the demands of 88 occupations based on interviews and observations at the work places was made at baseline. Thirteen job profile clusters emerged. Questionnaire information on health, lifestyle and socio-demographic factors was collected at baseline. In 2009, five Activities of Daily Living and seven Instrumental Activities of Daily Living tasks were assessed. A sum score of '0-12' was calculated using 12 dichotomous tasks where '0' indicates no difficulties in any tasks and '1-12' indicates increasing disability. Negative binomial regression was used to calculate rate ratios (RR) and their 95?% confidence intervals (CIs) for disability due to midlife job profiles.
After adjusting for age, socioeconomic, lifestyle and health-related characteristics, women in auxiliary (RR 2.1, 95?% CI 1.4-3.2), home care (2.1, 1.4-3.2), kitchen supervision (2.0, 1.1-3.6) and office (1.6, 1.1-2.4) job profiles had a higher risk of disability in later life than those in administrative jobs. Auxiliary (1.5, 1.1-2.9) and technical supervision (1.7, 1.1-2.7) job profiles carried an increased risk among men.
Midlife job profiles mainly linked with physically heavy work were strong predictors of disability in later life. In women, office work also increased the risk of disability.
PubMed ID
27146075 View in PubMed
Less detail

Midlife work ability and mobility limitation in old age among non-disability and disability retirees--a prospective study.

https://arctichealth.org/en/permalink/ahliterature276746
Source
BMC Public Health. 2016 Feb 16;16:154
Publication Type
Article
Date
Feb-16-2016
Author
Monika E von Bonsdorff
Taina Rantanen
Timo Törmäkangas
Jenni Kulmala
Timo Hinrichs
Jorma Seitsamo
Clas-Håkan Nygård
Juhani Ilmarinen
Mikaela B von Bonsdorff
Source
BMC Public Health. 2016 Feb 16;16:154
Date
Feb-16-2016
Language
English
Publication Type
Article
Keywords
Age Factors - complications - complications - complications
Aged - complications - complications - complications
Aged, 80 and over - complications - complications - complications
Aging - complications - complications - complications
Cardiovascular Diseases - complications - complications - complications
Disabled Persons - complications - complications - complications
Female - complications - complications - complications
Finland - complications - complications - complications
Health Status - complications - complications - complications
Humans - complications - complications - complications
International Classification of Functioning, Disability and Health - complications - complications - complications
Longitudinal Studies - complications - complications - complications
Male - complications - complications - complications
Mental Disorders - complications - complications - complications
Middle Aged - complications - complications - complications
Mobility Limitation - complications - complications - complications
Musculoskeletal Diseases - complications - complications - complications
Occupations - complications - complications - complications
Prospective Studies - complications - complications - complications
Retirement - complications - complications - complications
Surveys and Questionnaires - complications - complications - complications
Work - complications - complications - complications
Work Capacity Evaluation - complications - complications - complications
Abstract
Little is known about the wellbeing and mobility limitation of older disability retirees. Personal and environmental factors, such as time spent in working life, may either exacerbate or mitigate the onset of mobility limitation in general population. We aimed to study perceived midlife work ability as a determinant of self-reported mobility limitation in old age among municipal employees who transitioned into non-disability and disability retirement.
4329 participants of the Finnish Longitudinal Study of Municipal Employees (FLAME) had retired during January 1985 and July 2000. They had data on retirement, perceived work ability in 1985, and self-reported mobility limitation (non-disability retirement n = 2870, men 39%; and diagnose-specific disability retirement n = 1459, men 48%). Self-reported mobility was measured in 1985, 1992, 1997 and 2009. The latest score available was used to assess the number of mobility limitation. Work ability was measured by asking the respondents to evaluate their current work ability against their lifetime best in 1985. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for work ability predicting mobility limitation in non-disability and diagnose-specific disability retirement groups were calculated using Poisson regression models.
The prevalence of mobility limitation for those who transitioned into non-disability retirement (Incidence Rate, IR = 0.45, 95% CI = 0.44-0.46) was lower compared to those who retired due to disability (IR = 0.65, CI = 0.63-0.66). A one-point increase in the work ability score decreased the risk for having one more mobility limitation among non-disability and all diagnose-specific retirement groups (musculoskeletal disease, cardiovascular disease, mental disorder, and other diseases).
Better midlife work ability may protect from old age mobility limitation among those who retire due to non-disability and disability. Promoting work ability in midlife may lead to more independent, active aging, regardless of type of retirement.
Notes
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PubMed ID
26880684 View in PubMed
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Perceived stress symptoms in midlife predict disability in old age: a 28-year prospective cohort study.

https://arctichealth.org/en/permalink/ahliterature116696
Source
J Gerontol A Biol Sci Med Sci. 2013 Aug;68(8):984-91
Publication Type
Article
Date
Aug-2013
Author
Jenni Kulmala
Mikaela B von Bonsdorff
Sari Stenholm
Timo Törmäkangas
Monika E von Bonsdorff
Clas-Håkan Nygård
Matti Klockars
Jorma Seitsamo
Juhani Ilmarinen
Taina Rantanen
Author Affiliation
Gerontology Research Center and Department of Health Sciences, University of Jyväskylä, P.O. Box 35, FIN - 40014, Jyväskylä, Finland. jenni.kulmala@jyu.fi
Source
J Gerontol A Biol Sci Med Sci. 2013 Aug;68(8):984-91
Date
Aug-2013
Language
English
Publication Type
Article
Keywords
Activities of Daily Living
Adult
Aged
Aged, 80 and over
Aging - physiology - psychology
Cohort Studies
Disabled Persons
Female
Finland
Humans
Male
Middle Aged
Mobility Limitation
Prospective Studies
Risk factors
Stress, Psychological - physiopathology
Abstract
Stress has damaging effects on individual's health. However, information about the long-term consequences of mental stress is scarce.
This 28-year prospective cohort study examined on the associations between midlife stress and old age disability among 2,994 Finnish municipal professionals aged 44-58 years at baseline. Self-reported stress symptoms were assessed at baseline in 1981 and 4 years later in 1985 and perceived disability in 2009. For the baseline data, principal component analysis was used for differentiation into stress symptom profiles. The regression coefficient estimates for self-care disability (activities of daily living) and instrumental activities of daily living disability were estimated using left-censored regression. The odds ratios for mobility limitation were estimated using logistic regression.
Four midlife stress profiles were identified: negative reactions to work and depressiveness, perceived decrease in cognition, sleep disturbances, and somatic symptoms. We saw a clear gradient of increasing disability severity in old age for increasing intensity of midlife stress symptoms. In comparison with the participants with no stress symptoms, the extensively adjusted left-censored and logistic regression models showed that in old age, disability scores were almost 2-4 units higher and risk for mobility limitation was 2-3 times higher for those with constant stress symptoms in midlife.
Among occupationally active 44- to 58-year-old men and women, perceived stress symptoms in midlife correlated with disability 28 years later. Stress symptoms may be the first signs of decompensation of individual functioning relative to environmental demands, which may later manifest in disabilities.
PubMed ID
23371968 View in PubMed
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Persistence of the effect of birth size on dysglycaemia and type 2 diabetes in old age: AGES-Reykjavik Study.

https://arctichealth.org/en/permalink/ahliterature124360
Source
Age (Dordr). 2013 Aug;35(4):1401-9
Publication Type
Article
Date
Aug-2013
Author
Mikaela B von Bonsdorff
Majon Muller
Thor Aspelund
Melissa Garcia
Gudny Eiriksdottir
Taina Rantanen
Ingibjörg Gunnarsdottir
Bryndis Eva Birgisdottir
Inga Thorsdottir
Gunnar Sigurdsson
Vilmundur Gudnason
Lenore Launer
Tamara B Harris
Author Affiliation
Laboratory of Epidemiology, Demography and Biometry, Intramural Research Program, National Institute on Aging, Bethesda, MD, USA. mikaela.vonbonsdorff@jyu.fi
Source
Age (Dordr). 2013 Aug;35(4):1401-9
Date
Aug-2013
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Birth Weight - physiology
Blood Glucose - metabolism
Body mass index
Diabetes Mellitus, Type 2 - blood - epidemiology
Disease Progression
Female
Follow-Up Studies
Glucose Tolerance Test
Humans
Iceland - epidemiology
Incidence
Insulin - blood
Insulin Resistance - physiology
Male
Middle Aged
Population Surveillance - methods
Prospective Studies
Weight Gain
Abstract
We studied the effect of birth size on glucose and insulin metabolism among old non-diabetic individuals. We also explored the combined effect of birth size and midlife body mass index (BMI) on type 2 diabetes in old age. Our study comprised 1,682 Icelanders whose birth records included anthropometrical data. The same individuals had participated in the prospective population-based Reykjavik Study, where BMI was assessed at a mean age of 47 years, and in the AGES-Reykjavik Study during 2002 to 2006, where fasting glucose, insulin and HbA1c were measured and homeostasis model assessment for the degree of insulin resistance (HOMA-IR) calculated at a mean age of 75.5 years. Type 2 diabetes was determined as having a history of diabetes, using glucose-modifying medication or fasting glucose of >7.0 mmol/l. Of the participants, 249 had prevalent type 2 diabetes in old age. Lower birth weight and body length were associated with higher fasting glucose, insulin, HOMA-IR and HbA1c among old non-diabetic individuals. Higher birth weight and ponderal index at birth decreased the risk for type 2 diabetes in old age, odds ratio (OR), 0.61 [95 % confidence interval (CI), 0.48-0.79] and 0.96 (95 % CI, 0.92-1.00), respectively. Compared with those with high birth weight and low BMI in midlife, the odds of diabetes was almost five-fold for individuals with low birth weight and high BMI (OR, 4.93; 95 % CI, 2.14-11.37). Excessive weight gain in adulthood might be particularly detrimental to the health of old individuals with low birth weight.
Notes
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PubMed ID
22588637 View in PubMed
Less detail

Physical activity history and end-of-life hospital and long-term care.

https://arctichealth.org/en/permalink/ahliterature151653
Source
J Gerontol A Biol Sci Med Sci. 2009 Jul;64(7):778-84
Publication Type
Article
Date
Jul-2009
Author
Mikaela B von Bonsdorff
Taina Rantanen
Raija Leinonen
Urho M Kujala
Timo Törmäkangas
Minna Mänty
Eino Heikkinen
Author Affiliation
Department of Health Sciences, Finnish Centre for Interdisciplinary Gerontology, University of Jyväskylä, Finland. mikaela.bonsdorff@sport.jyu.fi
Source
J Gerontol A Biol Sci Med Sci. 2009 Jul;64(7):778-84
Date
Jul-2009
Language
English
Publication Type
Article
Keywords
Activities of Daily Living
Age Distribution
Aged
Aged, 80 and over
Cause of Death
Confidence Intervals
Data Collection
Female
Finland - epidemiology
Geriatric Assessment
Homes for the Aged - statistics & numerical data
Hospitalization - statistics & numerical data
Humans
Incidence
Length of Stay
Long-Term Care
Male
Nursing Homes - statistics & numerical data
Odds Ratio
Physical Fitness
Prospective Studies
Questionnaires
Risk assessment
Risk factors
Sex Distribution
Abstract
Little is known about the early predictors of need for care in late life. The purpose of this study was to investigate whether physical activity from midlife onward was associated with hospital and long-term care in the last year of life.
We studied a decedent population of 846 persons aged 66-98 years at death, who, on average 5.8 years prior to death, had participated in an interview about their current and earlier physical activity. Data on the use of care in the last year of life are register-based data and complete.
Men needed on average 96 days (SD 7.0) and women 138 days (SD 6.2) of inpatient care in the last year of life. Among men, the risk for all-cause hospital care in the last year of life was higher for those who had been sedentary since midlife (adjusted incidence rate ratio [IRR] 1.98, 95% confidence interval [CI] 1.14-3.42) compared with those who had been consistently physically active, whereas use of long-term care did not correlate with physical activity history. Among women, the risk for long-term care was higher for those who had been sedentary (IRR 2.03, 95% CI 1.28-3.21) or only occasionally physically active (IRR 1.60, 95% CI 1.06-2.43), than for those who had been consistently active from midlife onward, whereas use of hospital care did not correlate with physical activity history.
People who had been physically active since midlife needed less end-of-life inpatient care but patterns differed between men and women.
PubMed ID
19349592 View in PubMed
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Prenatal and childhood growth and physical performance in old age--findings from the Helsinki Birth Cohort Study 1934-1944.

https://arctichealth.org/en/permalink/ahliterature275214
Source
Age (Dordr). 2015 Dec;37(6):108
Publication Type
Article
Date
Dec-2015
Author
Johan G Eriksson
Clive Osmond
Mia-Maria Perälä
Minna K Salonen
Mika Simonen
Pertti Pohjolainen
Eero Kajantie
Taina Rantanen
Mikaela B von Bonsdorff
Source
Age (Dordr). 2015 Dec;37(6):108
Date
Dec-2015
Language
English
Publication Type
Article
Keywords
Adipose Tissue
Aged
Anthropometry
Birth weight
Body Height
Child
Child Development
Female
Fetal Development
Finland
Follow-Up Studies
Geriatric Assessment - methods
Humans
Infant
Infant, Newborn
Life Style
Male
Physical Fitness
Pregnancy
Social Class
Abstract
Health in adulthood is in part a consequence of development and growth taking place during sensitive periods in early life. It has not been explored previously whether early growth is associated with physical performance in old age from a life course perspective taking into account health-related behavior, biological risk factors, and early life experiences. At a mean age of 71 years, physical performance was assessed using the Senior Fitness Test (SFT) in 1078 individuals belonging to the Helsinki Birth Cohort Study. We used multiple linear regression analysis to assess the association between the SFT physical fitness scores and individual life course measurements. Several adult characteristics were associated with physical performance including socioeconomic status, lifestyle factors, and adult anthropometry. Higher birth weight and length were associated with better physical performance, even after adjusting for potential confounders (all p values
PubMed ID
26499818 View in PubMed
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Type of retirement as a determinant of pre- and post-retirement hospital in-patient care use: a prospective study.

https://arctichealth.org/en/permalink/ahliterature275980
Source
J Public Health (Oxf). 2015 Dec;37(4):707-15
Publication Type
Article
Date
Dec-2015
Author
Monika E von Bonsdorff
Taina Rantanen
Timo Törmäkangas
Jenni Kulmala
Jorma Seitsamo
Clas-Håkan Nygård
Juhani Ilmarinen
Mikaela B von Bonsdorff
Source
J Public Health (Oxf). 2015 Dec;37(4):707-15
Date
Dec-2015
Language
English
Publication Type
Article
Keywords
Adult
Female
Finland
Hospitalization - trends
Humans
Male
Middle Aged
Prospective Studies
Public Sector
Retirement
Abstract
We examined prospectively the use of all-cause hospital in-patient care among public sector employees by using a 3-year pre- and post-retirement study window.
A total of 5269 participants of the Finnish Longitudinal Study of Municipal Employees had retired during January 1984 and July 2000. They had register-based data on retirement (non-disability retirement n = 3411, men 40%, and diagnose-specific disability retirement n = 1858, men 50%) and all-cause hospital in-patient admissions and discharges. Analyses were conducted using Generalized Estimating Equation model.
The prevalence of hospital care use for non-disability retirees remained stable during the 6-year study window. The rate ratio (RR) for hospital care use increased in the year prior to retirement for men and women who transitioned into disability retirement due to cardiovascular disease and for women with disability due to mental disease. The RRs for hospital care use in the post-retirement year decreased for men who retired due to cardiovascular disease or mental disorders and for women who retired due to cardiovascular or musculoskeletal diseases.
An increase in hospital care preceding retirement in major diagnosis-specific disability retirement groups was followed by various patterns of decrease in the need of care indicated a beneficial health effect of retirement.
PubMed ID
25515822 View in PubMed
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Work ability as a determinant of old age disability severity: evidence from the 28-year Finnish Longitudinal Study on Municipal Employees.

https://arctichealth.org/en/permalink/ahliterature129497
Source
Aging Clin Exp Res. 2012 Aug;24(4):354-60
Publication Type
Article
Date
Aug-2012
Author
Mikaela B von Bonsdorff
Jorma Seitsamo
Juhani Ilmarinen
Clas-Håkan Nygård
Monika E von Bonsdorff
Taina Rantanen
Author Affiliation
Gerontology Research Centre, Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland. mikaela.vonbonsdorff@jyu.fi
Source
Aging Clin Exp Res. 2012 Aug;24(4):354-60
Date
Aug-2012
Language
English
Publication Type
Article
Keywords
Activities of Daily Living
Adult
Aged
Aging - physiology
Chronic Disease
Disability Evaluation
Female
Finland
Follow-Up Studies
Geriatric Assessment - methods
Humans
Life Style
Longitudinal Studies
Male
Middle Aged
Prospective Studies
Questionnaires
Self Care
Socioeconomic Factors
Task Performance and Analysis
Work - physiology
Abstract
Lower occupational class correlates with a higher disability risk later in life. However, it is not clear whether the demands made by mental and physical work relative to individual resources in midlife predict well-being in old age. This study investigated prospectively whether work ability in midlife predicts disability severity in activities of everyday living in old age.
Data come from the population-based 28-year follow-up called Finnish Longitudinal Study of Municipal Employees. A total of 2879 occupationally active persons aged 44-58 years answered a questionnaire on work ability at baseline in 1981 and activities of daily living in 2009. At baseline, perceived work ability relative to lifetime best was categorized into excellent, moderate, and poor work ability. At follow-up, disability scales were constructed based on the severity and frequency of difficulties reported in self-care activities of daily living (ADL) and instrumental activities of daily living (IADL).
There was a graded prevalence of ADL and IADL disability severity, according to excellent, moderate and poor midlife work ability (p
PubMed ID
22102525 View in PubMed
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Work ability in midlife as a predictor of mortality and disability in later life: a 28-year prospective follow-up study.

https://arctichealth.org/en/permalink/ahliterature137440
Source
CMAJ. 2011 Mar 8;183(4):E235-42
Publication Type
Article
Date
Mar-8-2011
Author
Mikaela B von Bonsdorff
Jorma Seitsamo
Juhani Ilmarinen
Clas-Håkan Nygård
Monika E von Bonsdorff
Taina Rantanen
Author Affiliation
Gerontology Research Centre, Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland. mikaela.vonbonsdorff@jyu.fi
Source
CMAJ. 2011 Mar 8;183(4):E235-42
Date
Mar-8-2011
Language
English
Publication Type
Article
Keywords
Activities of Daily Living
Adult
Aging - physiology
Disability Evaluation
Disabled persons - statistics & numerical data
Female
Finland - epidemiology
Follow-Up Studies
Humans
Longitudinal Studies
Male
Middle Aged
Mortality
Predictive value of tests
Proportional Hazards Models
Prospective Studies
Questionnaires
Retirement
Risk factors
Work
Abstract
Poor work ability correlates with increased morbidity and early retirement from the workforce, but the association in old age is not known. We investigated work ability in midlife among white-collar and blue-collar employees as a predictor of mortality and disability 28 years later.
A total of 5971 occupationally active people aged 44-58 years participated in the Finnish Longitudinal Study of Municipal Employees (FLAME) in 1981. Perceived work ability relative to lifetime best was categorized as excellent, moderate or poor. In 2009, the ability to perform activities of daily living was assessed among 2879 respondents (71.0% of the survivors). Mortality data were available up to July 2009.
At the 28-year follow-up, 1918 of the 5971 participants had died and 1403 had some form of disability. Rates of death per 1000 person-years among white-collar men were 7.7 for those with excellent work ability, 14.7 for those with moderate work ability and 23.5 for those with poor work ability. Among blue-collar men, the corresponding rates were 15.5, 20.2 and 25.3. In women, rates ranged between 6.3 and 10.6 per 1000 person-years. The age-adjusted hazard ratios (HRs) for mortality were two to three times higher among blue-collar male employees with lower work ability than among white-collar male employees with excellent work ability in midlife (i.e., the reference group). The odds of death or disability at follow-up compared with white-collar workers with excellent work ability were highest among blue-collar employees with poor work ability in midlife (odds ratio [OR] 4.56, 95% confidence interval [CI] 2.82-7.37 for men; OR 3.37, 95% CI 2.28-4.98 for women). Among the survivors, similar but slightly lower risks of disability 28 years later were found.
Perceived poor work ability in midlife was associated with accelerated deterioration in health and functioning and remains evident after 28 years of follow-up.
Notes
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PubMed ID
21282315 View in PubMed
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Work-related biomechanical exposure and job strain in midlife separately and jointly predict disability after 28 years: a Finnish longitudinal study.

https://arctichealth.org/en/permalink/ahliterature289921
Source
Scand J Work Environ Health. 2017 09 01; 43(5):405-414
Publication Type
Journal Article
Research Support, Non-U.S. Gov't
Date
09-01-2017
Author
K C Prakash
Subas Neupane
Päivi Leino-Arjas
Mikaela B von Bonsdorff
Taina Rantanen
Monika E von Bonsdorff
Jorma Seitsamo
Juhani Ilmarinen
Clas-Håkan Nygård
Author Affiliation
School of Health Sciences, University of Tampere, FI-33014, Tampere, Finland. Prakash.kc@uta.fi.
Source
Scand J Work Environ Health. 2017 09 01; 43(5):405-414
Date
09-01-2017
Language
English
Publication Type
Journal Article
Research Support, Non-U.S. Gov't
Keywords
Activities of Daily Living
Adult
Aging - physiology
Biomechanical Phenomena - physiology
Disability Evaluation
Female
Finland - epidemiology
Humans
Longitudinal Studies
Male
Middle Aged
Occupational Exposure
Prospective Studies
Risk factors
Stress, Psychological - physiopathology
Surveys and Questionnaires
Work - physiology - psychology
Abstract
Objectives We investigated whether the extent of biomechanical exposures and job strain in midlife separately and jointly predict disability in old age. Methods Participants of the Finnish Longitudinal Study on Aging Municipal Employees (FLAME) in 1981 (aged 44-58 years) responded to disability questionnaires in 2009 (1850 women and 1082 men). Difficulties in performing five activities of daily living (ADL) and seven instrumental ADL (IADL) were used to assess severity of disability (score range: 0-12, 0=no disability). Information on biomechanical exposures and job strain was collected by questionnaire at baseline. Adjusted prevalence proportion ratios (PR) and 95% confidence intervals (95% CI) were modelled using mixed negative binomial regression with robust variance. The joint effect of two exposures was quantified using the concept of relative excessive risk due to interaction (RERI). Results The overall prevalence of disability (score: 1-12) was 46.7% (women: 41%; men: 57%). Compared to low-level exposures in an adjusted model, the PR of high baseline biomechanical exposures for each one unit increase in the disability score was 1.31 (95% CI 1.10-1.55) and PR of high job strain was 1.71 (95% CI 1.26-2.32). Associations were rather similar in gender-stratified analyses. Furthermore, the joint effect (high strain/high biomechanical) was multiplicative (women: PR 1.32, 95% CI 1.21-1.45; men: PR 1.27, 95% CI 1.13-1.44), but no additive effect was observed when fully adjusted. Conclusion High biomechanical exposure and job strain in midlife were strongly associated with the severity of disability in later life. The workplace could serve as arena for preventive interventions regarding disability in old age.
PubMed ID
28653077 View in PubMed
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