Skip to main content

Synergistic associations of visual and self-reported hearing acuity with low handgrip strength in older adults: a population-based cross-sectional study



It is unclear whether visual and hearing acuity are independently or synergistically associated with muscle strength. We aimed to examine the associations of visual and self-reported hearing acuity with low handgrip strength and the additive interaction between visual and hearing acuity on low handgrip strength in people over 60 years.


Data of 3,075 individuals aged over 60 years from the 2017 and 2018 Korea National Health and Nutrition Examination Survey were used for this cross-sectional study. Low handgrip strength was defined based on the 20th percentile of the study population (< 30.4 kg for male and < 17.7 kg for female). Visual and self-reported hearing acuity were each divided into three categories: good, moderate, and impaired. Multiple logistic regression and relative excess risk due to interaction (RERI) were performed.


Of the 3,075 participants, 993 (32.3 %) demonstrated low handgrip strength. Low handgrip strength was more prevalent in participants with moderate (adjusted odds ratio [AOR] = 1.54, 95 % confidence interval [CI] = 1.12–2.12) and impaired visual acuity (AOR = 2.00, 95 % CI = 1.34–2.96). Both moderate and impaired self-reported hearing acuity were significantly associated with low handgrip strength (moderate: AOR = 1.25, 95 % CI = 1.01–1.55; impaired: AOR = 1.66, 95 % CI = 1.15–2.38). The more severe the sensory function decline, the higher the association with muscle weakness. Moreover, combined sensory impairments were associated with deteriorating low handgrip strength (AOR = 8.38), with significantly strong additive interactions (RERI = 2.61, 95 % CI = 2.52–2.70).


Awareness is needed regarding the risk of reduced muscle strength in individuals with moderate and impaired sensory function. Older people with sensory function decline in clinical settings may benefit from programs such as exercise prescription to prevent muscle weakness.

Peer Review reports


Age-related decline of physical function and increasing functional disability are associated with adverse health outcomes in older people, including reduced quality of life and increased all-cause mortality [1, 2]. Among the indicators of physical performance, such as gait speed, balance, and chair stand tests, handgrip strength employs simple and noninvasive measures to provide an estimate of the isometric strength of the upper limb [3]. Handgrip strength is considered an estimate of “overall strength” because it is related to the strength of other muscle groups [4]. Moreover, handgrip strength is also a useful predictor of nutritional status and an objective component of the frailty syndrome in older people [5,6,7]. Low handgrip strength (LHGS) is associated with reduced quality of life [8], and recent studies have shown that older people with LHGS are at a higher risk of suffering from disabilities and are more likely to be hospitalized [9, 10]. Furthermore, handgrip strength is an independent predictor of all-cause mortality and cardiovascular diseases [11, 12].

Visual and hearing impairment increase with age. In the older Korean population (aged ≥ 60 years), the prevalence of hearing loss is 16.8 % [13], and visual impairment is also a common problem [14]. Sensory impairments, including visual and/or hearing impairments, are associated with several problems that can arise in old age. Primarily, research has reported an association between vision and increased frequency of falls and an increase in the risk of recurrent falls in older women due to visual impairment [15, 16]. Furthermore, greater frailty, measured by gait speed, grip strength, peak expiratory flow rate, and the ability to rise from a chair without arm support, is associated with poorer visual functions [17]. Several studies have shown that older people with hearing impairment have increased functional disability, reduced ability to perform activities of daily living (ADL), and increased risk of frailty [18, 19].

Furthermore, the problem becomes aggravated if visual and hearing impairment occur concomitantly. Combined visual and hearing impairment have a greater effect on the functional status of ADL and instrumental activities of daily living than solitary sensory impairment [20]. Additionally, those with combined visual and hearing impairment report higher mortality risk than those with only a single sensory impairment [21].

Despite the functional connection between sensory and motor areas [22], little is known about the relationship between visual and hearing acuity, muscle weakness, and low muscle mass, which is an important cause of the decrease in physical function [4, 23, 24]. Sensory function is an indicator of healthy physical aging. Considering the common-cause theory, which suggests that generalized aging effects can simultaneously contribute to the development of sensory organ dysfunction and reduced muscle strength [25], we proposed that the decrease in visual and hearing acuity is related to LHGS. In addition, if a synergistic effect appears when the impairments of the two sensory organs are added, the priority of intervention will be different from a clinical and public health perspective. Furthermore, unlike handgrip strength measurement, gait speed—a frailty index—particularly requires sight- and hearing-based movement [26]. Therefore, it may be difficult to confirm the decline of physical function through the gait speed of older adults with only sensory impairment, which establishes the need to confirm the relationship between sensory organ function and grip strength.

Moreover, studies evaluating the association between sensory function and handgrip strength divided sensory function dichotomously (mainly into good or impaired); thus, the dose-response effect of sensory function decline on handgrip strength could not be evaluated [23, 24]. Owing to the sex difference in predictors of handgrip strength and association of age, physical activity, and body mass index (BMI) with LHGS in older Koreans [27], it is also necessary to consider these points for examining the relationship between sensory function decline and LHGS.

Therefore, we aimed to evaluate the association of visual and self-reported hearing acuity with LHGS in older Koreans. The current study used a measure that has more than two levels, which allows more sensitivity in comparing various degrees of impairment with those with normal acuity. Furthermore, we investigated the interaction of visual and hearing acuity with LHGS and performed subgroup analyses stratified by sex, age, physical activity level, and BMI.


Study population and data

This cross-sectional study used data obtained from the 2017 and 2018 Korea National Health and Nutrition Examination Survey (KNHANES), which is a nationwide population-based survey designed to acquire information regarding the health and nutrition of people in South Korea [28]. The survey was performed by the Korea Diseases Control and Prevention Agency (KCDA) and combines a health interview with a physical examination and nutrition survey. The trained staff such as doctors or medical technicians conducted the health interview and physical examinations at the mobile examination center, and the dieticians visited the households for nutritional surveys [29]. Complex and multi-stage probability sample design was used in KNHANES to provide an unbiased cross-sectional estimate of Korean population [29]. The detailed description of KNHANES has been published elsewhere [29, 30]. The KNHANES survey protocols were approved by the Institutional Review Board of the KCDA (IRB No. 2018-01-03-P-A), and the research complied with the tenets of the Declaration of Helsinki for medical research involving human participants. Written informed consent was obtained from all participants in KNHANES [31].

A total of 16,119 participants were involved in the 2017–2018 KNHANES. In this study, persons aged < 60 years were excluded (n = 11,563) because we aimed to evaluate the association of visual and hearing acuity with LHGS in older Koreans; those who did not undergo visual acuity evaluation or assessment via an auto-refractor/keratometer were also excluded (n = 952). Furthermore, those who answered “do not know,” refused to respond to the questions, or had missing data for the question, “Which statement best describes your hearing (without a hearing aid)?” were excluded (n = 12). Additionally, persons whose handgrip strength data were unavailable and those who did not answer the query regarding the dominant hand were excluded (n = 108). Finally, after excluding participants with missing variables in covariates in this study (n = 409), 3,075 participants (1,370 male and 1,705 female participants) were selected (Fig. 1).

Fig. 1
figure 1

Flow chart for study sample


The main dependent variable was LHGS. Handgrip strength was measured using a digital grip strength dynamometer (T.K.K 5401; Takei Scientific Instruments Co., Ltd., Tokyo, Japan) and the following method was employed: after determining the dominant hand for each participant through verbal queries, both hands of the participants were measured thrice alternately, starting with the dominant hand, which was followed by a resting period of 60 s. For measuring handgrip strength, participants were instructed to face forward while standing upright, straighten the shoulders, let both arms hang straight down naturally, and grasp the dynamometer with no flexion or extension of the wrist and elbow during the measurement. The maximum handgrip strength of the dominant hand was measured and used for the analysis. The criteria for LHGS were based on the 20th percentile of the study population [32]. Consequently, LHGS was defined as < 30.4 kg for male and < 17.7 kg for female in this study.

The independent variables were visual and self-reported hearing acuity. Visual acuity was measured at a distance of 4 m using an international standard vision chart based on the Snellen scale, called the Jins vision chart [33]. Participants’ visual acuity pertaining to each eye was evaluated, right eye followed by the left, with his or her existing refractive correction (if applicable). In cases where the measured visual acuity was < 0.8 in at least one eye based on the Jins vision chart, the participants underwent automated refraction using an auto-refractor/keratometer (KR8800; Topcon, Tokyo, Japan). Participants’ visual acuity was defined as the best corrected visual acuity (BCVA) based on the eye with the best acuity. Visual acuity was classified into three categories as follows: 0.8 (20/25) ≤ BCVA ≤ 1.0 (20/20) [good], 0.5 (20/40) ≤ BCVA ≤ 0.63 (20/32) [moderate], BCVA < 0.5 (20/40) [impaired] [34, 35]. Hearing acuity was measured as self-reported by the following question: “Which statement best describes your hearing (without a hearing aid)?” The responses were divided into three groups as follows: good (good), moderate (moderate trouble), and impaired (considerable trouble and almost deaf) [36]. Furthermore, owing to the lack of an established three-level classification standard for self-reported hearing acuity, hearing acuity accounting for the use of a hearing aid was defined as follows for the sensitivity analysis: good (good or normal hearing without hearing aid), moderate (moderate trouble without hearing aid), and impaired (moderate or considerable trouble with hearing aid and almost deaf).

Sociodemographic, health-related factors, and year of survey (2017, 2018) were all used as covariates in our study [37]. In sociodemographic factors, age was categorized into four groups as follows: 60–64 years, 65–69 years, 70–74 years, and \(\ge\)75 years. Other sociodemographic factors were categorized as follows: region (rural and metropolitan), educational level (under high school and college degree or above), job categories (white collar, pink collar, blue collar, and none), monthly household income quartiles, and marital status. Health-related factors comprised smoking status (never, past, and current), drinking (occasionally, 2–4 times/month, and 2–4 times/week), obesity status (obese and non-obese), physical activity level (low and high, high indicating ≥ 2.5 h of moderate-intensity physical activity or ≥ 1.25 h of high-intensity physical activity per week), and history of chronic disease (stroke, cardiovascular disease including myocardial infarction and angina, hypertension, and diabetes mellitus).

Statistical analysis

Chi-squared tests were performed to evaluate differences in the frequency and proportion of categorical variables. Multiple logistic regression analysis was conducted to examine the associations of visual and hearing acuity with LHGS, with adjustment for covariates. The results are presented as adjusted odds ratios (AORs) and 95 % confidence intervals (CIs). We examined multiplicative interaction using a series of logistic regression models with a product term and employed relative excess risk due to interaction (RERI) to investigate the presence of interactions on an additive scale of whether the combination of decreased visual and hearing acuity poses greater risk than the sum of their independent effects. RERI was calculated as the difference between the expected value based on the addition of the odds ratios of the two separate risk factors and the observed value in the dual exposed group [39], where RERI > 0 indicated a synergistic effect with decreased visual and self-reported hearing acuity. Multiple logistic regression was used to performed subgroup analyses; they were stratified by sex, age group, physical activity level, and BMI. Lastly, sensitivity analysis was performed to evaluate the association of hearing acuity considering the use of a hearing aid with LHGS (Table S1). All analyses were performed using Statistical Analysis Software (SAS, version 9.4, SAS, Inc., Cary, NC, USA), and a weighted logistic regression procedure was used to account for the complex and stratified sampling design. A two-sided p-value < 0.05 was considered to indicate statistical significance.


Table 1 presents the general characteristics of male and female participants with LHGS. Of the 3,075 participants, 993 (32.3 %) had LHGS. Participants with impaired visual acuity exhibited the highest proportion of LHGS (59.2 %, n = 87), followed by those with moderate visual acuity (48.8 %, n = 138) and those with good visual acuity (29.0 %, n = 768). The distribution of LHGS according to self-reported hearing acuity was also the same as that for visual acuity; LHGS was displayed by 137 (53.9 %) of 254 with impaired hearing acuity, 221 (40.1 %) of 551 with moderate hearing acuity, and 635 (28.0 %) of 2,270 with good hearing acuity.

Table 1 General characteristics of study subjects

Table 2 shows the results of factors associated with LHGS. Compared to participants with good visual acuity, those with moderate or impaired visual acuity demonstrated a higher risk of LHGS, after adjusting for covariates [moderate: AOR = 1.54, 95 % CI = 1.12–2.12, p = 0.009; impaired: AOR = 2.00, 95 % CI = 1.34–2.96, p < 0.001]. Participants with impaired hearing acuity demonstrated the highest risk of LHGS than those with good hearing acuity (AOR = 1.66, 95 % CI = 1.15–2.38, p = 0.007). The more severe the decline in sensory function, the higher the association with LHGS (p for trend in visual acuity < 0.001; p for trend in hearing acuity = 0.003). As age increased, risk of LHGS increased. Low level of physical activity was associated with an increased probability of LHGS (AOR = 1.34, 95 % CI = 1.06–1.68, p = 0.014), and history of stroke was associated with LHGS. However, participants with obesity were less likely to have LHGS (AOR = 0.67, 95 % CI = 0.56–0.80, p < 0.001). The sensitivity analysis for self-reported hearing acuity considering the use of hearing aid presented similar results to the main analysis (Table S1).

Table 2 Factors associated with low handgrip strength

Table 3 describes the synergistic interaction of visual and hearing acuity with LHGS on an additive scale. Despite no multiplicative interaction, we observed a statistically significant additive interaction between visual and hearing acuity on LHGS. In the analyses with good visual and hearing acuity as the reference category, impaired visual or hearing acuity alone were associated with increased odds of LHGS (impaired visual acuity alone: AOR = 1.72, 95 % CI = 1.06–2.78, p = 0.027; impaired hearing acuity alone: AOR = 1.56, 95 % CI = 1.04–2.36, p = 0.034). However, for participants with both risk factors, the AOR of LHGS increased significantly to 8.38 (95 % CI = 2.12–33.20, p = 0.003). The RERI was 2.61 (95 % CI = 2.52–2.70, p < 0.001). In other words, when impaired visual and hearing acuity were present together, the odds ratio was greater than the sum of the individual effects.

Table 3 Interactions between visual and hearing acuity in relation to low handgrip strength

Figure 2 presents the results of the stratified analyses. LHGS reported prominent associations with hearing acuity among male and with visual acuity among female participants. Moreover, older adults reported a prominent association between sensory dysfunction and LHGS. Individuals who were not obese or had low levels of physical activity in the moderate and impaired visual acuity group showed significantly increased odds of having LHGS (not obese: moderate visual acuity, AOR = 1.52, 95 % CI = 1.02–2.26, p = 0.034; impaired, AOR = 2.22, 95 % CI = 1.36–3.62, p = 0.002; low level of physical activity: moderate visual acuity, AOR = 1.71, 95 % CI = 1.13–2.58, p = 0.010; impaired, AOR = 2.26, 95 % CI = 1.40–3.65, p < 0.001).

Fig. 2
figure 2

Subgroup analyses stratified by sex, age group, physical activity level, and BMI. LHGS, low handgrip strength; BMI, body mass index; AOR, adjusted odds ratio; CI, confidence interval


This representative population-based study provided evidence that older Koreans with impaired visual acuity and those with moderate visual acuity had a higher risk of reduced muscle strength, as indicated by LHGS. Moreover, impaired and moderate self-reported hearing acuity were significantly associated with increased risk of LHGS, compared to good hearing acuity. The association between sensory organ function and LHGS demonstrated a progressively increasing pattern as visual and hearing acuity deteriorated. Our results are similar to those of previous research that poor self-rated eyesight was associated with LHGS, and multiple sensory impairments, including hearing impairment, were associated with lower adjusted mean handgrip strength [23, 24]. However, prior studies only divided visual and hearing acuity in a dichotomous manner to evaluate the association with handgrip strength, and there was no study in which hearing impairment alone was related to LHGS.

Notably, a combined interaction of impaired visual and hearing acuity that was greater than the sum of their individual impacts was identified. Compared to participants with good visual and hearing acuity, those with concomitant impaired visual and hearing acuity had up to eight times greater odds of having LHGS. Several studies have shown that combined or concurrent impaired visual and hearing acuity are associated with cognitive and functional decline [39], and functional dependence [40]. However, as far as we know, there have been no studies that have confirmed the synergistic association with LHGS by distinguishing the degree of visual and hearing acuity. We further analyzed the additive interaction to evaluate the synergistic association of visual and hearing acuity with handgrip strength using RERI; there was a strong additive interaction between impaired visual and hearing acuity. Since additive interaction depicts a higher absolute excess of cases than multiplicative interaction, it is very important to estimate the additive scale from a biological and public health perspective [41]. Thus, older people who have both visual and hearing impairments may need faster and more appropriate intervention to prevent deterioration of physical function.

The mechanism of the association between decreased visual and/or hearing acuity and LHGS remains unclear. There are several hypotheses proposing that decreased visual and/or hearing acuity are related to LHGS or overall muscle strength. Visual acuity plays a leading role in balance control by providing the nervous system with continuously updated information about the position and movement of body segments in relation to each other and the environment [42]. Consequently, older people with decreased visual acuity tend to avoid physical activity because of the fear of falling, and avoidance of physical activity causes decreased muscle strength as assessed by handgrip strength [43, 44]. In the case of hearing, it is possible that sensory deprivation, changes in resource allocation, and social isolation owing to hearing impairment may have affected LHGS [45]. However, one of the most persuasive mechanisms is that decreased visual and/or hearing acuity are early physiologic markers of LHGS. This could be explained using the common-cause theory, which states that one or more factors contribute to the development of both sensory impairments and LHGS. Aging might be one such factor [23, 25]. Vascular disease or inflammation could be another potential common causative factor [46,47,48]. Furthermore, sensory and muscle strength may share more than aging and vascular inflammation or disease as common causes. Finally, sensory impairments might be an early sign or a surrogate marker of the development of frailty or the aging process, which can be measured by handgrip strength [49, 50].

The subgroup analyses demonstrated prominent associations of LHGS with hearing acuity in male participants and with visual acuity in female participants. It is difficult to explain these sex-specific associations of visual and hearing acuity with LHGS. Sex-differences have been found in the predictors of LHGS [51], and these differences need to be studied further to examine the potential underpinnings of sex-specific associations of sensory impairment with physical fuction. Meanwhile, participants aged > 70 years reported a more pronounced association between sensory organ dysfunction and LHGS. This may be the effect of age-related changes in cross-modal deactivations [52], but further research is needed. The association of decreased visual and hearing acuity with LHGS was greater in participants with low levels of physical activity. Low physical activity level is a well-known factor predicting decreased overall muscle strength [53], and this result indicated that decline of sensory function and low physical activity level are more relevant to LHGS than low physical activity level only.

Several methods can be employed to determine cut-off values for LHGS, which reflect muscle strength as part of the defining criteria for sarcopenia [32, 54,55,56], and some studies have reported reference values for handgrip strength in the Korean population [57, 58]. In our study, the criteria for LHGS were based on the 20th percentile of the study population [32]. Thus, LHGS was defined as < 30.4 kg for male and < 17.7 kg for female. We did not use the reference values because the data from KNHANES are acquired annually and factors associated with handgrip strength, such as nutritional or smoking status, change with the passage of time. Hence, it was determined that the 20th percentile of the study population was a better representative of the total population at the time of the study, rather than the reference values determined in a particular year.

This study has the following limitations. First, the cross-sectional design of this study cannot confirm the causality between sensory function decline and LHGS. However, we mitigated these limitations by employing appropriate methods including adjusting sociodemographic characteristics and well-established risk factors for LHGS and evaluating dose-response relationship. Second, handgrip strength estimation may vary depending on the position or method of handgrip measurement [59]. Third, participants only underwent automated refraction using an auto-refractor/keratometer and thus, visual acuity might not have been fully corrected. Fourth, this study employed self-reported measures for evaluating hearing acuity, which may have incurred response bias resulting in validity issues. Popularly, hearing impairment is defined as pure-tone average thresholds > 40 dB using pure-tone audiometry [60]. However, pure-tone audiometry was not used in the 2017 and 2018 KNHANES. Several existing studies have employed similar self-reported measures to categorize hearing groups [36]; however, we tried to enhance the validity using sensitivity analysis. Additional longitudinal studies are needed to confirm the effect of sensory impairments on physical function such as handgrip strength through a method that can objectively evaluate sensory organ function. Fifth, we could not confirm the associations of LHGS with cognitive impairment in Koreans [61], as KNHANES did not contain information on cognitive function. However, KNHANES participants underwent physical examinations and answered a lengthy questionnaire; thus, it might be difficult for individuals with reduced cognitive function to participate. Lastly, although gait impairment is considerably affected by sensory organ dysfunction, KNHANES lacks such information, and it could not be evaluated.

Nevertheless, the present study has several strengths. First, to the best of our knowledge, this is the first study to identify the synergistic association of visual and hearing acuity with LHGS in the older Korean population. Furthermore, our study is based on a nationally representative survey and random cluster sampling. This makes the data more reliable and representative of the Korean population. Additionally, our findings indicate that awareness is needed regarding risk of reduced muscle strength in individuals with decline of sensory function, even if the level of sensory function decline is minor and not severe. The underlying mechanism and directionality in this relationship needs to be confirmed in future biological or longitudinal studies. Furthermore, if sensory function decline is found in the older participants in a clinical setting, it may be helpful to develop a program such as exercise prescription to prevent muscle weakness in the future.


The current study found that older people with decreased visual or hearing acuity had a higher risk of having LHGS than those with good visual or hearing acuity, and the associations differed based on the level of sensory function decline. Additionally, our results provided further evidence that concomitant decreased visual and hearing acuity may be synergistically associated with LHGS, which is considered an estimate of overall muscle strength. This implies that biological or longitudinal prospective studies are needed to understand the effect of decline of sensory organ function on reduced muscle strength. Moreover, in older people clinically diagnosed with sensory function decline, it may be necessary to develop a program to prevent future muscle weakness.

Availability of data and materials

All the KNHANES data used this study are available to the public and can be seen in the KNHANES official website (



Low handgrip strength


Activities of daily living


Body mass index


Korea National Health and Nutrition Examination Survey


Adjusted odds ratios


Confidence intervals


Relative excess risk due to interaction


  1. Stessman J, Rottenberg Y, Fischer M, Hammerman-Rozenberg A, Jacobs JM. Handgrip Strength in Old and Very Old Adults: Mood, Cognition, Function, and Mortality. J Am Geriatr Soc. 2017;65(3):526–32.

    Article  PubMed  Google Scholar 

  2. Gama EV, Damián JE, Pérez de Molino J, López MR, López Pérez M, Gavira Iglesias FJ. Association of individual activities of daily living with self-rated health in older people. Age Ageing. 2000;29(3):267–70.

    Article  CAS  PubMed  Google Scholar 

  3. Lee MR, Jung SM, Bang H, Kim HS, Kim YB. The association between muscular strength and depression in Korean adults: a cross-sectional analysis of the sixth Korea National Health and Nutrition Examination Survey (KNHANES VI) 2014. BMC Public Health. 2018;18(1):1123.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Wu Y, Pang Z, Zhang D, Jiang W, Wang S, Li S, Kruse TA, Christensen K, Tan Q. A cross-sectional analysis of age and sex patterns in grip strength, tooth loss, near vision and hearing levels in Chinese aged 50–74 years. Arch Gerontol Geriatr. 2012;54(2):e213-20.

    Article  PubMed  Google Scholar 

  5. Chainani V, Shaharyar S, Dave K, Choksi V, Ravindranathan S, Hanno R, Jamal O, Abdo A, Abi Rafeh N. Objective measures of the frailty syndrome (hand grip strength and gait speed) and cardiovascular mortality: A systematic review. Int J Cardiol. 2016;215:487–93.

    Article  PubMed  Google Scholar 

  6. Bohannon RW. Muscle strength: clinical and prognostic value of hand-grip dynamometry. Curr Opin Clin Nutr Metab Care. 2015;18(5):465–70.

    Article  PubMed  Google Scholar 

  7. Giampaoli S, Ferrucci L, Cecchi F, Lo Noce C, Poce A, Dima F, Santaquilani A, Vescio MF, Menotti A. Hand-grip strength predicts incident disability in non-disabled older men. Age Ageing. 1999;28(3):283–8.

    Article  CAS  PubMed  Google Scholar 

  8. Sayer AA, Syddall HE, Martin HJ, Dennison EM, Roberts HC, Cooper C. Is grip strength associated with health-related quality of life? Findings from the Hertfordshire Cohort Study. Age Ageing. 2006;35(4):409–15.

    Article  PubMed  Google Scholar 

  9. Simmonds SJ, Syddall HE, Westbury LD, Dodds RM, Cooper C, Aihie Sayer A. Grip strength among community-dwelling older people predicts hospital admission during the following decade. Age Ageing. 2015;44(6):954–9.

    Article  PubMed  Google Scholar 

  10. López-Teros T, Gutiérrez-Robledo LM, Pérez-Zepeda MU. Gait Speed and Handgrip Strength as Predictors of Incident Disability in Mexican Older Adults. J Frailty Aging. 2014;3(2):109–12.

    PubMed  Google Scholar 

  11. Wu Y, Wang W, Liu T, Zhang D. Association of Grip Strength With Risk of All-Cause Mortality, Cardiovascular Diseases, and Cancer in Community-Dwelling Populations: A Meta-analysis of Prospective Cohort Studies. J Am Med Dir Assoc. 2017;18(6):551.e17-.e35.

  12. Kim GR, Sun J, Han M, Park S, Nam CM. Impact of handgrip strength on cardiovascular, cancer and all-cause mortality in the Korean longitudinal study of ageing. BMJ Open. 2019;9(5):e027019.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kim JS. Prevalence and factors associated with hearing loss and hearing aid use in korean elders. Iran J Public Health. 2015;44(3):308–17.

    PubMed  PubMed Central  Google Scholar 

  14. Cho GE, Lim DH, Baek M, Lee H, Kim SJ, Kang SW. Visual Impairment of Korean Population: Prevalence and Impact on Mental Health. Invest Ophthalmol Vis Sci. 2015;56(8):4375–81.

    PubMed  Google Scholar 

  15. Salonen L, Kivelä SL. Eye diseases and impaired vision as possible risk factors for recurrent falls in the aged: a systematic review. Curr Gerontol Geriatr Res. 2012;2012:271481.

    PubMed  PubMed Central  Google Scholar 

  16. Rokicki W, Drozdzowska B, Czekajło A, Grzeszczak W, Wiktor K, Majewski W, Pluskiewicz W. Relationship between visual status and functional status and the risk of falls in women. The RAC-OST-POL study. Arch Med Sci. 2016;12(6):1232–8.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Klein BE, Klein R, Knudtson MD, Lee KE. Relationship of measures of frailty to visual function: the Beaver Dam Eye Study. Trans Am Ophthalmol Soc. 2003;101:191-6; discussion 6–9.

  18. Gopinath B, Schneider J, McMahon CM, Teber E, Leeder SR, Mitchell P. Severity of age-related hearing loss is associated with impaired activities of daily living. Age Ageing. 2012;41(2):195–200.

    Article  PubMed  Google Scholar 

  19. Kamil RJ, Betz J, Powers BB, Pratt S, Kritchevsky S, Ayonayon HN, Harris TB, Helzner E, Deal JA, Martin KJJoa, et al. Association of hearing impairment with incident frailty and falls in older adults. 2016;28(4):644–60.

  20. Keller BK, Morton JL, Thomas VS, Potter JF. The effect of visual and hearing impairments on functional status. J Am Geriatr Soc. 1999;47(11):1319–25.

    Article  CAS  PubMed  Google Scholar 

  21. Gopinath B, Schneider J, McMahon CM, Burlutsky G, Leeder SR, Mitchell P. Dual sensory impairment in older adults increases the risk of mortality: a population-based study. PLoS One. 2013;8(3):e55054.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Johansson RS. Sensory input and control of grip. In. Novartis Foundation Symposium: Wiley Online Library; 1998. p. 45–58.

  23. Gopinath B, Liew G, Burlutsky G, Mitchell P. Associations Between Vision, Hearing, and Olfactory Impairment With Handgrip Strength. J Aging Health. 2019;

    Article  PubMed  Google Scholar 

  24. Smith L, Allen P, Pardhan S, Gorely T, Grabovac I, Smith A, López-Sánchez GF, Yang L, Jackson SE. Self-rated eyesight and handgrip strength in older adults. Wien Klin Wochenschr. 2020;132(5–6):132–8.

    Article  PubMed  Google Scholar 

  25. Fischer ME, Cruickshanks KJ, Schubert CR, Pinto AA, Carlsson CM, Klein BE, Klein R, Tweed TS. Age-Related Sensory Impairments and Risk of Cognitive Impairment. J Am Geriatr Soc. 2016;64(10):1981–7.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Abellan van Kan G, Rolland Y, Andrieu S, Bauer J, Beauchet O, Bonnefoy M, Cesari M, Donini LM, Gillette Guyonnet S, Inzitari M, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an International Academy on Nutrition and Aging (IANA) Task Force. J Nutr Health Aging. 2009;13(10):881–9.

  27. Kim CR, Jeon YJ, Jeong T. Risk factors associated with low handgrip strength in the older Korean population. PLoS One. 2019;14(3):e0214612.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Lee YH, Kim SU, Song K, Park JY, Kim DY, Ahn SH, Lee BW, Kang ES, Cha BS, Han KH. Sarcopenia is associated with significant liver fibrosis independently of obesity and insulin resistance in nonalcoholic fatty liver disease: Nationwide surveys (KNHANES 2008–2011). Hepatology. 2016;63(3):776–86.

    Article  CAS  PubMed  Google Scholar 

  29. Kweon S, Kim Y, Jang MJ, Kim Y, Kim K, Choi S, Chun C, Khang YH, Oh K. Data resource profile: the Korea National Health and Nutrition Examination Survey (KNHANES). Int J Epidemiol. 2014;43(1):69–77.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Kim Y. The Korea National Health and Nutrition Examination Survey (KNHANES): current status and challenges. Epidemiol Health. 2014;36:e2014002.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Han E, Lee YH, Lee BW, Kang ES, Lee IK, Cha BS. Anatomic fat depots and cardiovascular risk: a focus on the leg fat using nationwide surveys (KNHANES 2008–2011). Cardiovasc Diabetol. 2017;16(1):54.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  32. Chen LK, Liu LK, Woo J, Assantachai P, Auyeung TW, Bahyah KS, Chou MY, Chen LY, Hsu PS, Krairit O, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95–101.

    Article  PubMed  Google Scholar 

  33. Jin YHJJotKOS. A new LogMAR vision chart: Jins vision chart. 1997;38(11):2036–44.

    Google Scholar 

  34. Laitinen A, Koskinen S, Härkänen T, Reunanen A, Laatikainen L, Aromaa A. A nationwide population-based survey on visual acuity, near vision, and self-reported visual function in the adult population in Finland. Ophthalmology. 2005;112(12):2227–37.

    Article  PubMed  Google Scholar 

  35. Swenor BK, Lee MJ, Tian J, Varadaraj V, Bandeen-Roche K. Visual Impairment and Frailty: Examining an Understudied Relationship. J Gerontol A Biol Sci Med Sci. 2020;75(3):596–602.

    Article  PubMed  Google Scholar 

  36. Davies HR, Cadar D, Herbert A, Orrell M, Steptoe A. Hearing Impairment and Incident Dementia: Findings from the English Longitudinal Study of Ageing. J Am Geriatr Soc. 2017;65(9):2074–81.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Oh SS, Jang JE, Lee DW, Park EC, Jang SI. Cigarette type or smoking history: Which has a greater impact on the metabolic syndrome and its components? Sci Rep. 2020;10(1):10467.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Andersson T, Alfredsson L, Källberg H, Zdravkovic S, Ahlbom A. Calculating measures of biological interaction. Eur J Epidemiol. 2005;20(7):575-9.

  39. Lin MY, Gutierrez PR, Stone KL, Yaffe K, Ensrud KE, Fink HA, Sarkisian CA, Coleman AL, Mangione CM. Vision impairment and combined vision and hearing impairment predict cognitiveand functional decline in older women. J Am Geriatr Soc. 2004;52(12):1996–2002.

    Article  PubMed  Google Scholar 

  40. Reuben DB, Mui S, Damesyn M, Moore AA, Greendale GA. The prognostic value of sensory impairmentin older persons. J Am Geriatr Soc. 1999;47(8):930–5.

    Article  CAS  PubMed  Google Scholar 

  41. Knol MJ, VanderWeele TJ. Recommendations for presenting analyses of effect modification and interaction. Int J Epidemiol. 2012;41(2):514-20.

  42. Kulmala J, Viljanen A, Sipilä S, Pajala S, Pärssinen O, Kauppinen M, Koskenvuo M, Kaprio J, Rantanen T. Poor vision accompanied with other sensory impairments as a predictor of falls in older women. Age Ageing. 2009;38(2):162-7.

  43. Tan BKJ, Man REK, Gan ATL, Fenwick EK, Varadaraj V, Swenor BK, Gupta P, Wong TY, Trevisan C, Lorenzo-Lopez L, et al. Is Sensory Loss an Understudied Risk Factor for Frailty? A Systematic Review and Meta-analysis. J Gerontol A Biol Sci Med Sci. 2020 Jul 6;glaa171. doi: 10.1093/gerona/glaa171.  ;

  44. Moon JH, Oh YH, Kong MH, Kim HJ. Relationship between visual acuity and muscle mass in the Korean olderpopulation: a cross-sectional study using Korean National Health and NutritionExamination Survey. BMJ Open. 2019;9(12).

  45. Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incidentdementia. Arch Neurol. 2011;68(2):214–20.

  46. Kang SH, Jung DJ, Cho KH, Park JW, Lee KY, Do JY. Association between sarcopenia and hearing thresholds in postmenopausal women. Int J Med Sci. 2017;14(5):470-6.

  47. Bergman B, Nilsson-Ehle H, Sjöstrand J. Ocular changes, risk markers for eye disorders and effects of cataract surgery in elderly people: a study of an urban Swedish population followed from 70 to 97 years of age. Acta Ophthalmol Scand. 2004;82(2):166-74.

  48. Schaumberg DA, Christen WG, Buring JE, Glynn RJ, Rifai N, Ridker PM. High-sensitivity C-reactive protein, other markers of inflammation, and the incidence of macular degeneration in women. Arch Ophthalmol. 2007;125(3):300-5.

  49. Liljas AEM, Carvalho LA, Papachristou E, De Oliveira C, Wannamethee SG, Ramsay SE, Walters KR. Self-reported vision impairment and incident prefrailty and frailty in Englishcommunity-dwelling older adults: findings from a 4-year follow-up study. JEpidemiol Community Health. 2017;71(11):1053–8.

    Google Scholar 

  50. Chen CY, Wu SC, Chen LJ, Lue BH. The prevalence of subjective frailty and factors associated withfrailty in Taiwan. Arch Gerontol Geriatr. 2010;50(Suppl 1):S43-7.

    Article  PubMed  Google Scholar 

  51. Gopinath B, Kifley A, Liew G, Mitchell P. Handgrip strength and its association with functional independence, depressive symptoms and quality of life in older adults. Maturitas. 2017;106:92–4.

    Article  PubMed  Google Scholar 

  52. Peiffer AM, Hugenschmidt CE, Maldjian JA, Casanova R, Srikanth R, Hayasaka S, Burdette JH, Kraft RA, Laurienti PJ. Aging and the interaction of sensory cortical function and structure. Hum Brain Mapp. 2009;30(1):228-40.

  53. Roubenoff R. Sarcopeniaand its implications for the elderly. Eur J Clin Nutr. 2000;54(Suppl 3):S40-7.

    Article  PubMed  Google Scholar 

  54. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16-31.

  55. Tanimoto Y, Watanabe M, Sun W, Sugiura Y, Tsuda Y, Kimura M, Hayashida I, Kusabiraki T, Kono K. Association between sarcopenia and higher-level functional capacity in dailyliving in community-dwelling elderly subjects in Japan. Arch Gerontol Geriatr. 2012;55(2):e9-13.

    Article  PubMed  Google Scholar 

  56. Yu R, Wong M, Leung J, Lee J, Auyeung TW, Woo J. Incidence, reversibility, risk factors and theprotective effect of high body mass index against sarcopenia incommunity-dwelling older Chinese adults. Geriatr Gerontol Int. 2014;14(Suppl 1):15–28.

    Article  PubMed  Google Scholar 

  57. Kim CR, Jeon YJ, Kim MC, Jeong T, Koo WR. Reference values for hand grip strength in the South Koreanpopulation. PLoS One. 2018;13(4).

  58. Yoo JI, Choi H, Ha YC. Mean Hand Grip Strength and Cut-off Value for Sarcopenia in Korean Adults UsingKNHANES VI. J Korean Med Sci. 2017;32(5):868–72.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Boadella JM, Kuijer PP, Sluiter JK, Frings-Dresen MH. Effect of self-selected handgrip position onmaximal handgrip strength. Arch Phys Med Rehabil. 2005;86(2):328–31.

    Article  PubMed  Google Scholar 

  60. Alattar AA, Bergstrom J, Laughlin GA, Kritz-Silverstein D, Richard EL, Reas ET, Harris JP, Barrett-Connor E, McEvoy LK. Hearing Impairment and Cognitive Decline in Older, Community-Dwelling Adults. J Gerontol A Biol Sci Med Sci. 2020;75(3):567–73.

    Article  CAS  PubMed  Google Scholar 

  61. Jang JY, Kim J. Association between handgrip strength and cognitive impairment in elderlyKoreans: a population-based cross-sectional study. J Phys Ther Sci. 2015;27(12):3911–5.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


We would like to thank the KCDA, which provided the data based on a nationwide survey.


No funding was received for conducting this study.

Author information

Authors and Affiliations



SHK and ECP were responsible for the conception and design of the study. SHK, KH and YP performed the data curation, and SHK made contributions to analysis and interpretation of the data. SHK was drafted the manuscript. SIJ and ECP were performed writing review and editing, and all authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Eun-Cheol Park.

Ethics declarations

Ethics approval

The KNHANES survey protocols were approved by the Institutional Review Board of the KCDA (IRB No. 2018-01-03-P-A), and the research complied with the tenets of the Declaration of Helsinki for medical research involving human subjects. Written informed consent was obtained from all participants.

Consent for publication

All of the authors approved the manuscript’s submission for publication.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kim, S.H., Hurh, K., Park, Y. et al. Synergistic associations of visual and self-reported hearing acuity with low handgrip strength in older adults: a population-based cross-sectional study. BMC Geriatr 21, 513 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: