Gender Issues in the Care of Elderly: A Narrative Review

Abstract

Aging is an inevitable physiological process. A significant increase has been noted in the elderly population over the years. Aging population face challenges with physical health conditions, but also mental health problems. Care of the elderly is influenced by health conditions, health services, as well socio cultural factors. Gender plays an important role in the aging process with significant differences noted in the aging process, variations in health conditions as well care received. The current review addresses the role of gender in the aging process and its influence in the prevalence, clinical presentation and course of various mental and physical health conditions in the elderly. The review identifies gaps in understanding the gender perspectives related to long-term elderly care, legal and financial issues. The review emphasizes the necessity to address the gender perspective in aging to adequately meet the health demands of the elderly.

Introduction

Population aging is accelerating substantially across the world, including the middle and low-income countries. By 2050, we can anticipate a doubling of the proportion of people above 60 years of age.¹ It is anticipated that the population will further increase three times from 96.30 million in 2011 to 300.96 million in 2051.² Population aging brings with it many challenges and opportunities that need to be addressed. The longer one lives, the more he/she can fulfill his/her dreams and support the younger generation. However, the ability to seize these opportunities is majorly influenced by the person’s health. Physical health problems such as hearing loss, cataracts, arthritis, diabetes, and hypertension are common in this age group.¹ In addition to a risk of decline in physical health, aging is also associated with life transitions, role changes, grief, loneliness, and elder abuse, increasing the vulnerability to mental health problems. Depression is responsible for 5.7% years lived with disability (YLD) in people above 60 years. The mental health needs of the elderly population are often unidentified, not prioritized, and hence, not comprehensively managed.³ However, as we anticipate a great increase in the elderly population proportion, it becomes important that we understand the concerns specific to this population.

Geriatric care involves understanding various issues that influence the aging process, including evaluating the different biological and social aspects that influence aging and providing comprehensive care. World Health Organization (WHO) considers gender as an important determinant of health across all age groups. Gender differences in morbidity and mortality have been extensively studied, and women have 4 years to 5 years higher life expectancy. But this gender gap has been showing a declining trend over the years.⁴ While it comes to the elderly, recent research has shown that self-assessed health may be the same in either gender, but disability seems to be more pronounced in women.⁵ Despite the differences in the morbidity and mortality among older men and women, the issues related to elderly care and gender care have not been extensively researched. Gender-sensitive care has been stressed upon in various health systems, but the research in geriatric care is limited. The current review attempts to understand the various influences gender has on the care of the elderly. The review focuses on understanding gender influence in the normal aging process, physical health, mental health, and gender influence on various socioeconomic factors affecting elderly care.

Role of Gender in the Aging Process

Gender influences aging’s physiological, anatomical, emotional, and cognitive aspects.^6,1 Research into the physiology of the aging process shows that gender differences influence it in biological processes of genetics and immunology. Preliminary evidence shows that genetic polymorphisms like (A/C)-110 polymorphism in the promoter region of the HSP70-1 gene are associated with female longevity. Immunosenescence occurs earlier in men than women causing higher inflammatory responses associated with aging in men.⁷ The role of the hormones becomes significant wherein testosterone delays immunological responses leading to faster deterioration of immunity in men. In women, estrogen plays a protective role which delays atherosclerosis and has a better immune response. Women are also known to have a higher physiological reserve, i.e., higher capability to function under stress, than men, which causes them to accumulate more injuries over time, thus increasing morbidity.⁸ Preliminary research has also shown disruption in metabolism and mitochondrial functioning in neuronal cells during the transition to the perimenopausal stage associated with lack of estrogen. Hence, estrogen may have a role in reducing the risk of dementia.⁹

Anatomically, men, as they age, show greater volume reductions in the frontal lobes. In contrast, women tend to have prominent reductions in hippocampal and parietal lobe volumes leading to greater memory deficits.¹⁰ Generally, women perform better on tasks of verbal fluency and perceptual speed, while men have better visuospatial skills and mathematical reasoning.¹¹ Nevertheless, these findings are inconsistent and heavily influenced by education and exposure to various literary and cultural activities. Regarding emotions, women experience more negative emotions such as nervousness, guilt, and hostility at old age compared to men.¹² Emotional regulation strategies among the elderly appear to show gender differences; suppression appears to be more common among women even though maladaptive strategies are seen equally among men and women.¹³ The emotional, cognitive, and anatomical differences in aging also influence the further development of health problems in the elderly.

Gender Issues in Geriatric Health

• Frailty

  Frailty is an important aspect to consider when discussing the health of the elderly. Frailty is a “clinically recognizable state in older people who have increased vulnerability, resulting from age-associated declines in physiological reserve and function across multiple organ systems, such that the ability to cope with every day or acute stressors is compromised.”¹⁴ More than 10% of people above 65 years in the community are frail. A recent systematic review has shown that elderly females have a higher frailty index of 0.69 than men, 0.61.¹⁵ This finding has been seen in a study from low- and middle-income countries, including India.¹⁶ The gender difference in frailty has been attributed to many factors: higher fatal comorbidities in men, more number of chronic health conditions in women, and higher accumulation of abdominal fat in women, which leads to chronic inflammation, demands of pregnancy and child-rearing in women, or probable bias in reporting of poor health status by women. Frailty indicates a higher vulnerability to disease-related processes and is a better indicator of health.¹⁴ A recent study on frailty–cognitive associations in the elderly revealed a higher effect of frailty on executive function performance in males than females. In contrast, females had a higher effect of frailty on memory performance and neurocognitive speed.¹⁷ At the same time, gender did not seem to influence when health outcomes were examined in the presence of frailty and multimorbidity during psychiatric hospitalization in the elderly.¹⁸

• Physical Health

  Physical health problems form a major part of morbidity in the elderly. Noncommunicable diseases (NCD) form the major causes of disability-adjusted life years (DALY), more than 25000 per 100000 population.¹⁹ Even though NCDs were earlier considered primarily associated with men, current evidence shows that 75% of death and disabilities in women are contributed by NCD.²⁰ In terms of major causes of mortality and morbidity, cardiovascular and cerebrovascular diseases are important in both genders (Table 1). Cancer is another major health priority for aging men and women. Lung, prostate, stomach, and colorectal cancer are the most common cancers in older males worldwide. However, in India, oral cancer has the highest incidence (57.6 per 100,000), followed by prostate, lung, and esophagus in men. There are also chronic disabling conditions specific to men which need attention like urinary incontinence, benign prostate hyperplasia and erectile dysfunction.^22,23 Breast, colorectal, lung, and stomach cancer form the four most common types of cancer among women. In India, breast cancer continues to be the most common cause (93.1/100,000), followed by the cervix, ovary, and oral cavity. Osteoarthritis and osteoporosis also form important causes of disability in aging women.²⁴

• Mental Health

  Gender plays a crucial factor in mental health, with differences in incidence, clinical manifestation, and treatment outcomes. Common mental disorders such as depression, anxiety are more prevalent in women than men. However, this gender gap in the prevalence reduces in the elderly compared to the early adult years. This attenuation is unclear, but the higher risk for women above 65 years remains with a country-wise difference in years lived with common mental disorders.²⁵

  Depression

  Older women report more depressive symptoms than men, even though depression decreases with age for both genders similarly. Depressed men have a higher risk of mortality compared to depressed women.²⁶ Gender differences in depression could be attributed to differences in reporting, coping styles, the influence of social and cultural norms.²⁵ Among multiple psychosocial predictors of depression studied in the elderly, gender difference has been studied only in social support. However, data evaluating gender differences in social support in the elderly shows mixed results.²⁶

  Severe Mental Illness

  Although there might not be a significant difference in the prevalence rates in severe mental disorders, gender definitely impacts the course, severity, and long-term outcome.²⁷ Women have a second peak of onset of schizophrenia during the perimenopausal period. It is also seen that late-onset schizophrenia has more severe symptoms.²⁵

  Suicide

  Suicide rates in the elderly follow the pattern of younger age groups, i.e., higher suicide mortality rates for older men and higher suicide attempts in older women.²⁵ Single, divorced, and widowed women are at a higher risk of completing suicide. Bereavement increases the risk of suicide in the partner, and males have higher suicide rates and take more time to recover from the loss.²⁸

  Dementia

  Dementia forms another major concern for the aging population. As the life expectancy increases, the prevalence rates of dementia are also expected to increase. Dementia is more prevalent in women than men; however, the incidence rates seem similar. The risk factors of dementia-like smoking, diabetes, and hypertension, are seen more in men, so vascular dementia specifically has a higher incidence in men.

  Bereavement

  Bereavement is a major life event in the elderly. Loss of the spouse is an inevitable experience that often brings about major changes in various aspects of an older adult’s life. Even though older people cope better with the loss of a spouse, bereaved spouses have higher rates of mortality and morbidity, more depressive symptoms, increased health care costs, and higher rates of hospitalization. Over the age of 65, 41% of women are widowed than 13% in men and further rise with an increase in age.²⁹ Complicated grief is seen to be more persisting in men than women, contributing to loneliness.³⁰

  Loneliness

  Loneliness encompasses “a complex set of feelings which is an after-effect of social isolation.” It can include social loneliness, which is an absence of belonging to a community, or emotional loneliness, which lacks connection to attachment figures. Loneliness affects a decline in the rate of motor decline and mobility.³¹ However, it is also seen that women tend to have more social relationships after losing a partner than men; hence men experience more effects of loneliness.³² Individuals who experience loneliness are more susceptible to depression and cognitive decline.³¹

• Sexual Health

  Sexual health plays a major part in maintaining good physical and mental health. A US based population survey revealed 38.9% of men being sexually active as compared to 16.8% women among individuals between 75 years to 85 years.³³ Even though a decline in sexual activity is seen with an increase in age for both genders, men have a higher quality of sexual life and sexual interest. Female sexual activity is more affected by life stressors, contextual factors, and mental health problems. Sexual dysfunction is also an important determinant of sexual activity in the elderly. Erectile dysfunction is the most common sexual dysfunction in men due to age-related changes, vascular or neurological problems. Lack of desire and arousal is the most common sexual dysfunction among older women, occurring mostly due to menopause-related atrophy of vaginal and vulvar membranes, urogenital prolapse, and urinary incontinence. Hence, it becomes crucial that a detailed assessment of sexual health be done in the elderly.³⁴

• Elder abuse

  Elder abuse is defined as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. It can be of various forms: physical, psychological, emotional, sexual, and financial, or reflect intentional or unintentional neglect”.³⁵ Elder abuse is a major public health problem with a prevalence of 15.7% in individuals above 60 years. While the limited data shows that older men and women are at equal risk of abuse, there are cultures where women have a higher risk of neglect, financial abuse with more severe forms of abuse.³⁶

• Long-Term Care

  As women have a higher life expectancy, a higher percentage of women live alone than men and have lower likelihood of being cared for by a family member, which increases the need for long-term care services in women. However, women’s utilization of long-term care services is affected by unaffordability, poor quality of services, and possible maltreatment in these facilities.^37,38 United Nations policy brief 2017 on gender priority in long-term care of older people acknowledged the lack of quality long-term care services and their inadequate utilization by older women. The policy brief highlighted the need to engage women’s rights organizations and gender equality advocates in framing long-term care policies and developing a gender-responsive continuum of long-term care, extending from home-based services to intensive institutional care.³⁸

Table 1.

Difference in Mortality Rates of Major Causes of Death Between Women and Men Between 60 Years – 64 Years Globally²¹

Major Causes of Mortality-Globally	Mortality Rate in Men Between 60 Years – 64 Years (Per 100,000)	Mortality Rate in Elderly Women Between 60 Years – 64 Years (Per 100,000)
1.  Cardiovascular diseases	886.85	579.42
2.  Ischemic heart disease	549.94	309.17
3.  Malignant neoplasms	307.56	242.94
4.  Stroke	270.61	198.70
5.  Respiratory diseases	237.79	177.10

Socioeconomic Factors Affecting Elderly Care

Health-seeking behavior in the elderly is less as compared to other age groups. In India, older women report poorer health status and have higher unmet health needs than their male counterparts. Despite this, it is seen in many countries, including India, that men have better access to health care. Indian older women with heart disease are less likely to seek help, less likely to have access to investigations and treatment, and are underrepresented in research. There could be various reasons for this gender difference, including gender-based discrimination, poor socioeconomic conditions, and more focus on women’s reproductive health, which doesn’t include women in the elderly age group.^39,24

Older women are seen to engage more in unpaid labor, less pension availability, and have lesser authority over financial resources than men. Poverty is more common in widows, which increases their vulnerability to health problems.⁴⁰ These gender inequities affect the availability of resources that could interfere with the care given to the elderly.

Conclusion

Despite significant advances in understanding the gender differences in aging and illnesses, there is a gap in understanding the role of gender as a determinant of health and care in the elderly population. The review highlights that gender influences various aspects of the normal aging process, which affects the physical and mental health of the elderly. There is evidence for older women being more vulnerable to mental health problems, elder abuse, and experiencing a lower quality of sexual life. Despite this, they have lesser access to health care services and receive low-quality long-term care. There is also a need to identify gender differences regarding economic and legal issues in the elderly such as rehabilitation, financial autonomy, will making, and guardianship. Moving ahead, policies targeting improving geriatric care must take a gender-sensitive approach to reduce the gender inequality in resource availability. There is a need for further research exploring the causes for gender differences in various mental health problems, which can help with more efficient management of these problems. It also becomes imperative that we address the concerns of elderly sexual minorities who have been neglected so far. Geriatric care has to target improving independence, quality of life, and longevity of the elderly while being gender-sensitive.