Gender Differences in Function, Physical Activity, Falls Medication Use and Life Satisfaction Among Assisted Living Residents

Abstract

The purpose of this study was to test for gender differences among assisted living residents. This was a secondary data analysis using data from the first 64 facilities participating in the ongoing Function Focused Care for Assisted Living study using the Evidence Integration Triangle (FFC-AL-EIT). A total of 593 residents were recruited from 64 assisted living settings. Differences by gender with regard to function, physical activity, falls, total numbers of medications, and satisfaction with assisted living were tested using multivariate analysis of variance. There were 166 males (28%) and 427 females (72%) with a mean age of 88 (SD=7.5). The participants had 5 comorbidities (SD= 2) and took on average 6.88 medications (SD=3.47). Participants had moderate functional impairment with a mean of 64.13 (SD=19.09) on the Barthel Index and engaged in 43.80 (SD=76.12) minutes daily of moderate level physical activity. Females reported higher satisfaction with activities [4.32 (SD=1.14) for females and 3.85 (SD=1.51) for males] and females received more medications than males [7.09 (SD=3.51) for females and 6.34 (SD=3.31) for males]. Current study findings suggest that deprescribing may be particularly important for females versus males and focusing on expanding activity options to include those preferred by males should be considered in AL settings.

Gender is defined as “environmental, social, and cultural influences on the biological factors in women and men (Isaksson, Graneheim, Åstrom, & Karlsson, 2011).” The impact of gender has not been extensively studied among older adults with regard to clinical outcomes such as function, physical activity, falls, medication use and satisfaction with life or living situation. Moreover, the research that has been done was mostly based on community dwelling older adults.

Gender Differences in Function and Physical Activity

It has repeatedly been noted that community dwelling older males tend to have better function and engage in more physical activity than their female counterparts (Ahmed et al., 2018; Ahmed, Vafaei, Auals, Guralnik, & Zunzunegui, 2016; Finkel, Andel, & Pedersen, 2018; Shaw, Liang, Krause, Gallant, & McGeever, 2010; Small, Dixon, McArdle, & Grimm, 2012). Females tend to decline more in physical activity with age than males (Bruun, Maribo, Nørgaard, Schiøttz-Christensen, & Mogensen, 2017; Finkel et al., 2018; Oshio & Oshio, 2012) and are less likely to reach recommended levels of physical activity (Lin, Yeh, Chen, & Huang, 2010). Females also tend to participate more in social (e.g., church) rather than physical activities (Finkel et al., 2018; Oshio & Oshio, 2012; Zhang, Feng, Lacanienta, & Zhen, 2017).

The research done exploring gender differences in physical activity among individuals living in facilities has been inconsistent and sample or study specific. In one recent study in a geriatric rehabilitation facility it was noted that males reported greater life space and thus engaged in more physical activity than females (Ullrich et al., 2019). Conversely, several studies of assisted living residents reported that males spent more time in sedentary activity than females (Bellettiere et al., 2015; Leung et al., 2017). Similarly, there were differences in the association between gender and falls among older adults. Some reports suggested that females were more likely to fall (Pauelsen, Nyberg, Roijezon, & Vikman, 2018; Sotoudeh, Mohammadi, Mosallanezhad, Viitasara, & Soares, 2018), some noted that males were more likely to fall (Cameron, Bowles, Marshall, & Andrew, 2018; Vieira de Sousa et al., 2016), while others noted no association between gender and falls (Bor et al., 2017).

Gender Differences in Satisfaction with Living Situation and Overall Life Satisfaction

Satisfaction with living in a nursing home has been associated with gender such that males were less likely to experience adjustment problems than females and tended to report less dissatisfaction with the facility (Claridge, Rowell, Duffy, & Duffy, 1995; Greenwood, 1999). Similarly, life satisfaction, including physical, psychological, social, and environmental domains, was rated higher by older male versus older female nursing home residents (Barca, Engedal, Laks, & Selbaek, 2011; Onunkwor et al., 2016; Vitorino, Paskulin, & Vianna, 2012). The same findings were noted among males and females living in the community (Read, Grundy, & Foverskov, 2016). Differences in life satisfaction between males and females may vary based on the country in which the individual lives and the setting of care. Countries in which there is greater gender inequality tend to note gender differences in life satisfaction between males and females, with men expressing more satisfaction (Read et al., 2016; Sole-Auro, Jasilionis, Li, & Oksuzyan, 2018; Zhang et al., 2017).

Medication Use and Gender Differences

Polypharmacy is an important area to consider given the impact of multiple medications on the risk of falls, delirium, and other geriatric syndromes. Although polypharmacy is common among all older adults, females tend to experience more polypharmacy (Midao, Giardini, Menditto, Kardas, & Costa, 2018; Rozenfeld, Fonseca, & Acurcio, 2008) and greater exposure to potentially inappropriate medications compared to males (Herr et al., 2017). Most studies of older adults in the community or in nursing homes note that females receive more pain medication than males including opioids (Hunnicutt et al., 2018; Sandvik, Selbaek, Kirkevold, SHusebo, & Aarsland, 2016). Females are also more likely to be prescribed anxiolytics, antipsychotics, and antidepressants (Dore, Piras, Lorettu, & Pes, 2016; Fog, Straand, Engedal, & LBlix, 2019; Kettunen et al., 2019).

Currently over 31,000 assisted living (AL) settings nationwide serve almost 750,000 older adults (Congressional Budget Office, 2013). Nearly 40% of residents in ALs require assistance with three or more activities of daily living (ADLs) and the majority need help with meal preparation and medication management (American Association of Homes and Services for the Aging, 2009). They have multiple chronic conditions and an average length of stay of two years (American Association of Homes and Services for the Aging, 2009). Residents in ALs are sedentary and experience functional decline beyond what is expected from disease progression (Resnick et al., 2018; Zimmerman, 2013). Limited physical activity increases residents’ risk for falls, pain, pressure ulcers and hospitalizations (Chung, 2013; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011b) and decreases quality of life (Kim & Park, 2014; Lapane, 2012). Given the increase in individuals living in assisted living settings and the potential gender differences in clinical outcomes with regard to function, physical activity, medication use, falls and life satisfaction or satisfaction with their living situation in these settings, the purpose of this study was to explore gender differences across multiple outcomes among assisted living residents. Specifically we hypothesized that there would be significant differences between male and female residents with regard to function, physical activity, falls, number of medications given as well as differences in use of specific psychotropic and pain medications, and satisfaction with assisted living. Knowing if there are differences in these outcomes in assisted living residents based on gender will provide an important first step to developing gender specific interventions to address these outcomes.

Methods

Design and Sample

This study was a secondary data analysis using data from the first 64 facilities participating in an ongoing randomized trial testing the dissemination and implementation of Function Focused Care for Assisted Living study using the Evidence Integration Triangle (FFC-AL-EIT). The study was approved by a University based Institutional Review Board. AL settings were invited to participate if they: (1) had at least 25 beds; (2) identified a staff member (i.e., registered nurse, licensed practice nurse, direct care worker, social worker) to work with the study team in the implementation of the FFC-AL-EIT intervention; and (3) were able to access email and websites via a phone, tablet, or computer. Sites were randomized to treatment or Education Only (EO). AL residents were eligible to participate if they were 65 years of age or older, able to speak English, living in a participating assisted living facility at the time of recruitment, and able to recall at least one out of three words as per the Mini-Cog (Borson, Scanlan, Chen, & et al, 2003). Residents were excluded if they were enrolled in hospice. A five-item Evaluation to Sign Consent (Resnick et al., 2007) questionnaire was used to determine the residents’ capacity to provide consent to participate in the study. If the resident did not pass the Evaluation to Sign Consent, he or she was asked to assent to the study and consent was obtained from the resident’s legally authorized representative. A total of 593 residents were recruited into the study from 64 assisted living settings across Maryland, Pennsylvania, and Massachusetts.

Measures

Measures for the parent study were collected at baseline, 4, and 12 months post implementation of the intervention, although only baseline data were used in this analysis. Data were collected by research assistants all of whom had prior experience working with this population. The following resident descriptive information was obtained: age, gender, number of comorbidities based on chart data, falls in the four month period prior to implementation of the study provided by facility staff, medications based on chart data (including the following: medications for depression, anxiety, gastrointestinal problems, seizure, pain including opioids, anemia, hyperlipidemia, diabetes, osteoporosis, anticoagulation, sedative hypnotics, Parkinson’s disease, prostate disease, steroids, antipsychotics, allergies, and chemotherapeutic agents), and cognitive status which was based on the Mini-Cog screening tool (Borson et al., 2003), specifically the individual’s ability to recall 0, 1, 2, or 3 out of 3 words. The Mini-Cog was developed as a brief screening tool to identify those with likely dementia. The Mini-Cog has sensitivity ranging from 76–99%, and specificity ranging from 89–93% with a 95% confidence interval (Borson et al., 2003). The Barthel Index (Mahoney & Barthel, 1965) was used to evaluate function. The Barthel Index includes 10-items that address activities of daily living (e.g., bathing, dressing). Items are weighted to account for the amount of assistance required. A score of 100 indicates complete independence. Estimates of internal consistency ranged from alpha coefficients of 0.62 to 0.80, inter-rater reliability was supported based on an intra-class correlation of 0.89 between two observers; and validity was based on correlations with the Functional Inventory Measure (r=0.97, p<.05)(Mahoney & Barthel, 1965). Data was obtained via verbal report of function from the direct care worker providing care for the resident on the day of testing.

Residents’ satisfaction with the assisted living setting was assessed using four subscales from the Resident Satisfaction Index (RSI) (Sikorska-Simmons, 2001). The four subscales from the RSI focused on: (1) the residents’ perceptions of health care (4 items: e.g., are you satisfied with the skills of the staff you interact with); (2) the physical environment (4 items: e.g., do you lack personal space); (3) relationships with staff (8 items: e.g., are the staff kind and caring); and (4) physical and social activities (5 items: e.g., do you like the physical and social activities here). Participants were asked to agree (1) or disagree (0) with each item and scores were totaled such that higher scores were indicative of higher resident life satisfaction. Prior research has supported internal consistency and validity based on factor analysis and significant correlations with psychological well-being (Sikorska-Simmons, 2001).

Physical activity was based on accelerometry data collected with the Motionwatch 8 (CamNtech, 2018) and specifically time spent in moderate level physical activity. The MotionWatch 8 is a compact, lightweight, wrist-worn activity monitoring device used to document physical movement. The Motionwatch 8 contains a miniature accelerometer to allow measurement and recording of physical movement of the wrist, which provides a close correlation to whole body movement. Reliability, validity, and cut points for different levels of activity based on counts of activity have been established for older adults (Landry, Falck, Beets, & Liu-Ambrose, 2015). The cut points established for moderate level physical activity were > 562 counts per minute (Landry et al., 2015). Counts are the unit of measurement used to evaluate activity when calculated by any type of actigraph. The device counts the number of times the waveform crosses 0 for each time period being evaluated. Moderate level physical activity was used as this is the basis of recommended guidelines for older adults (i.e., 30 minutes daily of moderate level physical activity) and thus allows for comparisons across multiple samples. The Motionwatch 8 was placed on participants for 5 days with data evaluated for the three full days between placement and removal (i.e., days 2, 3, and 4). There was no significant difference in activity on days 2, 3, and 4 and so day 2 data was used for all analyses.

Data Analysis

Descriptive analyses were done to describe the sample including a t-test to describe differences in age and comorbidities between males and females. Differences by gender with regard to function, physical activity, falls, total numbers of medications, and satisfaction with assisted living as per our hypothesis were tested using multivariate analysis of variance. Multivariate analysis of variance was used to test the effect of the independent variable (gender) on a set of two or more dependent variables. Absence of multivariate outliers was checked by assessing Mahalanobis Distances among the participants. The critical value for the Mahalonobis Distance was 24.01 and there was no evidence of outliers. All variables met the assumption of linearity and there was no evidence of multicollinearity. The Box’s M test was used to evaluate if covariance matrices were equal. The Box’s M was significant (Box’s M = 52.85, F=1.43, p=.05) so the Pillai-Bartlett trace was used to determine multivariate significance (Cohen, 2008). There was no association between age and comorbidities with function, physical activity, falls, medication use or satisfaction with assisted living so these factors were not controlled for in the analysis.

To test for differences in specific drug group use (being on at least one drug within each group, e.g., one antidepressant, one pain medication) between males and females chi-square analyses were performed. A p≤ .05 level of significance was used for all analyses.

Results

There were 166 males (28%) and 427 females (72%) in the study with an overall mean age of 88 (SD=7.19). The participants had approximately 5 comorbidities (SD= 2) and took on average 6.88 medications (SD=3.47). Overall the Resident Life Satisfaction subscales scores were high with the mean Health Care Satisfaction being 3.59 (SD=.81) out of a total score of 4, mean Physical Environment Satisfaction at 4.35 (SD=.93) out of a total possible score of 5, mean Relationships with Staff equal to 7.09 (SD=1.27) out of a total possible score of 8, and mean Satisfaction with Activities being 4.19 (SD=1.28) out of a possible score of 5. There was evidence of moderate functional impairment with a mean of 64.13 (SD=19.09) on the Barthel Index out of a total score of 100 indicating independence. The participants engaged in 43.80 (SD=76.12) minutes daily of moderate level physical activity based on the Motionwatch 8 recordings. Twenty-five percent of the participants experienced at least one fall over the four months prior to the start of the study.

Multivariate test results are shown in Table 1. The Pillai’s Trace was significant for gender with an F=2.10 (p=.02). Females reported higher satisfaction with activities provided in the setting [4.32 (SD=1.14) for females and 3.85 (SD=1.51) for males, F=10.28, p=.01] and females received slightly more medications than males [7.09 (SD=3.51) for females and 6.34 (SD=3.31) for males, F=2.09, p=.05]. There were no differences with regard to falls, function, physical activity, or satisfaction with the physical environment, relationships with staff, or health care.

Table 1.

Multivariate Analysis and Description of Outcomes by Gender (bolded outcomes significant at the p≤.05 level)

Variable	Male Mean (SD)	Female Mean (SD)	Total Mean (SD)	F	p
Age	88 (8.10)	89 (7.24)	88 (7.19)	1.97	.16
Comorbidities	5 (2.00)	5 (2.01)	5 (2.00)	.019	.89
Medications	6.34(3.31)	7.09(3.51)	6.88 (3.47)	2.09	.05
Health Satisfaction With Care	3.60(.74)	3.58(.85)	3.59 (.81)	.05	.81
Physical Environment Satisfaction	4.27(.89)	4.38(.94)	4.35 (.93)	1.11	.29
Relationship with Staff Satisfaction	7.09(1.23)	7.09(1.29)	7.09 (1.27)	.001	.89
Satisfaction with Activities	3.85(1.51)	4.32(1.14)	4.19 (1.28)	10.28	.01
Function	65.45(17.60)	63.58(19.68)	64.13 (19.09)	.73	.39
Moderate level physical activity	41.92(76.94)	45.67(75.30)	43.80 (76.12)	.19	.67
Falls	N (%)	N(%)		.001	.98
Yes	41(25%)	101(25%)	142 (25%)
No	125(75%)	326(75%)	326 (75%)

Table 2 provides the frequency of medication use by gender. Across both groups the most commonly prescribed medications included medications for osteoporosis, hyperlipidemia, gastrointestinal problems, anticoagulants, and antidepressants. The rate of use of opioids was low at 4 – 8%, as was the rate of sedative hypnotics at 2 – 4%, anxiolytics at 3 – 9% and antipsychotics at 9 – 13%. Females were significantly more likely than males to get steroids (36% of females versus 24% of males, χ² =7.22, p=.007), medications for osteoporosis (50% of females versus 34% of males, χ² =12.22, p=.001), medications for cardiovascular disease (39% of females versus 29% of males, χ² =5.61, p=.018), pain medications including opioids (30% of females versus 18% of males, χ² =8.67, p=.003), anxiolytics (9% of females versus 3% of males, χ² =6.16, p=.013), and antidepressants (45% of females versus 32% of males, χ² =8.09, p=.004).

Table 2.

Differences in Medication Use By Gender

Medication	Male	Female	χ2	P*
Cholinesterase Inhibitors			1.79	.18
Yes	22(13%)	76(18%)
No	144(87%)	351(82%)
Parkinson’s Medications			.10	.76
Yes	9(5%)	26(6%)
No	157(95%)	401(94%)
Urinary Incontinence Medications			.98	.32
Yes	12(7%)	42(10%)
No	154(93%)	385(90%)
Steroids			7.22	.007
Yes	40(24%)	152(36%)
No	126(76%)	275(64%)
Osteoporosis Medications			12.22	.001
Yes	56(34%)	212(50%)
No	110(66%)	215(50%)
Cardiovascular Medications			5.61	.018
Yes	48(29%)	168(39%)
No	118(71%)	259(61%)
Diabetes Medications			.001	.99
Yes	28(17%)	72(17%)
No	138(83%)	355(83%)
Antilipid Medications			1.28	.29
Yes	76(46%)	175(41%)
No	90(54%)	252(59%)
Anticoagulants			3.29	.07
Yes	88(53%)	191(45%)
No	78(47%)	236(55%)
Anemia Medication			.44	.51
Yes	24(15%)	53(12%)
No	142(85%)	374(88%)
Pain Medication (including opioids)			8.67	.003
Yes	30(18%)	128(30%)
No	136(82%)	299 (70%)
Opioids Only			3.00	.08
Yes	6(4%)	32(8%)
No	160(96%)	395(92%)
Seizure Medication			.06	.81
Yes	32(19%)	86(20%)
No	134(81%)	341(80%)
Gastrointestinal Medications			2.52	.112
Yes	88(53%)	257(60%)
No	78(47%)	170(40%)
Anxiolytics			6.16	.013
Yes	5(3%)	38(9%)
No	161(97%)	389(91%)
Antidepressants			8.09	.004
Yes	53(32%)	191(45%)
No	113(68%)	236(55%)
Antipsychotics			1.87	.171
Yes	21(13%)	38(9%)
No	145(87%)	389(91%)
Sedative Hypnotics			1.51	.22
Yes	7(4%)	10 (2%)
No	159(96%)	417(98%)

^*p<.05

Discussion

The findings from this study provided partial support for the hypothesis that there would be a significant difference between males and females in assisted living settings with regard to function, physical activity, falls, medication use and satisfaction with assisted living. In this sample the only differences noted by gender were related to number of and types of some medications given and satisfaction with activities. Females were noted to be more satisfied with activities and to take significantly more medications than males. Higher satisfaction with activities within assisted living settings by females versus males is not surprising given that older females generally tend to enjoy and engage in more social activity than older males (Finkel et al., 2018; Oshio & Oshio, 2012; Zhang et al., 2017). Conversely, older males are more likely to engage in less social activities such as reading and exercise (Zhang et al., 2017). There were no differences noted by gender with regard to satisfaction with the care provided, relationships with staff, or the environment. Overall satisfaction with assisted living was actually quite high across all these areas which is consistent with a national survey of resident satisfaction completed by the Assisted Living Federation of America(Assisted Living Federation of America, 2016; Hoban, 2010). Future research should continue to explore the factors that influence resident satisfaction with activities and how these are different between genders. These findings will help guide the types of activities males versus females prefer and expand on types of activities needed to improve participation and satisfaction across both genders.

Our findings related to medication use were similar to other studies noting that females used more medications than males (Midao et al., 2018; Morgan et al., 2016; Niclós, Olivar, & Rodilla, 2018; Rozenfeld et al., 2008). The rates of use across both males and females were consistent with polypharmacy, defined as taking five or more medicines (Viktil, Moger, & Reikvam, 2007), and raises concerns about the risk of potentially inappropriate medications (Herr et al., 2017; The 2019 American Geriatrics Society Beers Criteria® Update Expert Panel, 2019). For example, the high use of medications for osteoporosis and hyperlipidemia could be questioned given the average age of the participants and the questionable value of these medications at this point in their lives. Likewise, the high rate of anticoagulant use, with aspirin being the most common treatment, needs to be reconsidered given the current guidelines recommending against aspirin use for those greater than 70 years of age without a significant history of cardiovascular disease (United States Preventive Services Taskforce, 2018).

Females, as has been previously noted, were more likely to be treated for pain (Hunnicutt et al., 2018; Sandvik et al., 2016) using a variety of pain medications. The actual rate of opioid use was lower among this sample than has been seen in some nursing home samples (Fog et al., 2019; Griffioen, Husebo, Flo, Caljouw, & Achterberg, 2017; Sandvik et al., 2016) although the rates were similar to a recent report of nursing homes from Maryland and Pennsylvania (Resnick et al., in press). It is possible that the low rate of opioid use is due to a current focus on decreasing opioids nationally (Dowell, Haegerich, & Chou, 2016). Future research needs to continue to explore gender differences and the use of and need for opioids versus other treatment modalities for pain among assisted living residents.

The rate of antipsychotic medication use (9 – 13%) in this sample of assisted living residents was lower than the national current rate of 15.7% of residents in nursing homes in the United States (Centers for Medicare and Medicaid, 2018). The sample rates were, however, higher than the rate of 9% reported from nursing home residents in the United Kingdom (Ballard, Corbett, Orrell, & et al, 2018). Although there was not a significant difference between genders with regard to antipsychotic use, consistent with prior research (Kamble, Chen, Sherer, & Aparasu, 2008), males tended to be more likely to receive antipsychotics than females.

The rate of antidepressant use was similar to that found in other studies both among community dwelling and nursing home residents (Fog et al., 2019; Helvik, Saltytė Benth, Wu, Engedal, & Selbæk, 2017; Koller, Hua, & Bynum, 2016; MacLagan et al., 2017; Maust, Langa, Blow, & Kales, 2017). As noted previously there was no difference in treatment between males and females (Blumstein, Benyamini, Shmotkin, & Lerner-Geva, 2014; Jacob & Kostev, 2016). Generally the rate of use of sedative hypnotics and anxiolytics was lower in our assisted living sample than other studies that included community dwelling and nursing home residents(Fog et al., 2019; Resnick et al., in press). As has been previously noted, however, women were more likely to be receiving anxiolytics. Further a study of Israeli older adults noted differences in the factors that influence use of anxiolytics between males and females such that age, not being married, sleeping problems and depressive symptoms were significant correlates of use of anxiolytics among males while any life trauma and being married correlated with use of anxiolytics among females (Blumstein et al., 2014). Continued research is needed to test the associated of these factors with use of anxiolytics and then develop interventions to help address these factors and decrease medication use. For example, married women may be using anxiolytics due to the stress of caregiving for a spouse. Help with caregiving may be able to offset that stress.

In contrast to prior research noting that males tended to be more physically active and functionally intact than females (Ahmed et al., 2018; Ahmed et al., 2016; Finkel et al., 2018; Ullrich et al., 2019; Zhang et al., 2017) we noted no gender differences in this study. It is possible that there is more homogeneity of physical activity and function among those who live in assisted living versus those in the community (Phillips et al., 2018; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011a).

Although there was no difference in the amount of activity performed between males and females, it has been suggested that there are differences in barriers and facilitators to physical activity between males and females. Several qualitative reports (Kwon et al., 2016; Sandlund et al., 2018) noted that there are differences in barriers to walking for females versus males. Specifically, females describe neighborhood safety concerns, chronic medical conditions and pain as barriers to physical activity while males note that barriers include laziness or low self-efficacy associated with walking. Facilitators for walking among females were fear of nursing home placement and fear of falling and a desire for weight maintenance or loss. Conversely males were more interested in exercise as a way to maintain function and keep fit. Future research in assisted living should continue to explore for differences in function and physical activity between genders and identify the factors that serve as facilitators and barriers to function and physical activity across genders.

As has been shown in other studies of assisted living residents (Hummer, Silva, Yap, Toles, & Anderson, 2015; Naylor et al., 2016; Resnick et al., 2011a), the participants in this study needed some help with activities of daily living based on the Barthel Index. Despite needing help with activities of daily living, the study participants engaged in more than the recommended amount of moderate level physical activity and more activity than previously reported among older adults in assisted living(Corcoran et al., 2016; Leung et al., 2017; Resnick et al., 2011a). Current study participants were noted to engage in a mean of 43.80 (SD=76.12) minutes of moderate level physical activity daily while participants in another study of physical activity among assisted living residents were noted to spend only one minute in moderate to vigorous physical activity (Leung et al., 2017). We anticipate that these differences are based on measurement issues including the type of device used and the setting of counts per level of activity. The Motionwatch 8 was set based on prior research with older adults so that moderate level physical activity was greater than or equal to 562.50 counts per minute. This is in contrast to the Actigraph, which was used in the Leung et al., study, with settings based on the Freedson equation (Freedson, Melanson, & Sirard, 1998). The Freedson calculation defines moderate level activity as 1,964 counts per minute and may underestimate the amount of energy expended by older individuals (Pruitt et al., 2008).

There was no difference in the frequency of falls between males and females in our sample. Some prior research has likewise reported no difference between the two groups with regard to falls or fall risks (Alves Guimarães et al., 2018; Cameron et al., 2018; Lastrucci, Lorini, Rinaldi, & Bonaccorsi, 2018). Falls are due to multiple factors and gender may be less important than physical activity, balance, cognition, or the environment

Study Limitations

This study was limited in that it was a secondary data analysis and not designed to test for gender differences among participants. The study included residents from 64 facilities from three states and there may have been some bias in the sample as these were all individuals who consented to participate in the parent FFC-AL-EIT study. Further the function data may have been biased as it was based on recall of the staff that worked with the resident on the day of testing. It is possible that the staff reported on the care they provided to the resident versus truly measuring what the resident was able to perform him or herself. The completion of the Resident Life Satisfaction survey may have been biased due to social desirability and fear on the part of the resident to say anything negative about the facility. Despite these limitations, the findings of this study provide some indication that there may be differences among males and females with regard to medication use and satisfaction with activities. Continued evaluation of gender differences in these settings should be done to help guide how care is provided. Current study findings suggest that deprescribing may be particularly important for females versus males and focusing on expanding activity options to include those preferred by males should be considered in AL settings.