Gender is defined as “environmental, social, and cultural influences on the biological factors in women and men” (Isaksson, Graneheim, Åström, & Karlsson, 2011, p. 573). 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 men tend to have better function and engage in more physical activity than their female counterparts (Ahmed, Vafaei, Auals, Guralnik, & Zunzunegui, 2016; Ahmed et al., 2018; Finkel, Andel, & Pedersen, 2018; Shaw, Liang, Krause, Gallant, & McGeever, 2010; Small, Dixon, McArdle, & Grimm, 2012). Women tend to decline more in physical activity with age than men (Bruun, Maribo, Nørgaard, Schiøttz-Christensen, & Mogensen, 2017; Finkel et al., 2018; Oshio, 2012) and are less likely to reach recommended levels of physical activity (Lin, Yeh, Chen, & Huang, 2010). Women also tend to participate more in social (e.g., church) rather than physical activities (Finkel et al., 2018; Oshio, 2012; Zhang, Feng, Lacanienta, & Zhen, 2017).
Research 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 men reported greater life space and thus engaged in more physical activity than women (Ullrich et al., 2019). Conversely, several studies of residents in assisted living settings reported that men spent more time in sedentary activity than women (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 women were more likely to fall (Pauelsen, Nyberg, Roijezon, & Vikman, 2018; Sotoudeh, Mohammadi, Mosallanezhad, Viitasara, & Soares, 2018), some noted that men were more likely to fall (Cameron, Bowles, Marshall, & Andrew, 2018; Vieira de Sousa et al., 2016), whereas 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 men were less likely to experience adjustment problems than women 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, & Selbæk, 2011; Onunkwor et al., 2016; Vitorino, Paskulin, & Vianna, 2012). The same findings were noted among men and women living in the community (Read, Grundy, & Foverskov, 2016). Differences in life satisfaction between men and women 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 men and women, with men expressing more satisfaction (Read et al., 2016; Solé-Auró, 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 poly-pharmacy is common among all older adults, women tend to experience more polypharmacy (Midão, Giardini, Menditto, Kardas, & Costa, 2018; Rozenfeld, Fonseca, & Acurcio, 2008) and greater exposure to potentially inappropriate medications compared to men (Herr et al., 2017). Most studies of older adults in the community or nursing homes note that women receive more pain medication than men, including opioids (Hunnicutt et al., 2018; Sandvik, Selbaek, Kirkevold, Aarsland, & Husebo, 2016). Women are also more likely to be prescribed anxiolytic, antipsychotic, and antidepressant medications (Dore, Piras, Lorettu, & Pes, 2016; Fog, Straand, Engedal, & Blix, 2019; Kettunen et al., 2019).
More than 31,000 assisted living settings nationwide serve approximately 750,000 older adults (Congressional Budget Office, 2013). Approximately 40% of residents in assisted living settings 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 [AAHSA], American Seniors Housing Association, Assisted Living Federation of America, National Center for Assisted Living, & National Investment Center for the Seniors Housing and Care Industry, 2009). They have multiple chronic conditions and an average length of stay of 2 years (AAHSA et al., 2009). Residents in assisted living settings are sedentary and experience functional decline beyond what is expected from disease progression (Resnick et al., 2018; Zimmerman et al., 2013). Limited physical activity increases residents' risk for falls, pain, pressure ulcers, and hospitalizations (Chung, 2013; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011) and decreases quality of life (Kim et al., 2014; Lapane, Quilliam, Chow, & Kim, 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 the current study was to explore gender differences across multiple outcomes among residents in assisted living settings. Specifically, the authors 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 residents in assisted living settings based on gender will provide an important first step to developing gender-specific interventions to address these outcomes.
Design and Sample
The current 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 using the Evidence Integration Triangle (FFC-AL-EIT) (Resnick, Galik, et al., 2019). The study was approved by a university-based Institutional Review Board. Assisted living settings were invited to participate if they: (a) had at least 25 beds; (b) identified a staff member (e.g., RN, licensed practical nurse, direct care worker, social worker) to work with the study team in the implementation of the FFC-AL-EIT intervention; and (c) were able to access e-mail and websites via a phone, tablet, or computer. Assisted living residents were eligible to participate if they were age ≥65, able to speak English, living in a participating assisted living facility at the time of recruitment, and able to recall at least one of three words as per the Mini-Cog (Borson, Scanlan, Chen, & Ganguli, 2003). Residents were excluded if they were enrolled in hospice. A five-item Evaluation to Sign Consent questionnaire (Resnick et al., 2007) was used to determine a resident's 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 for the parent study were collected at baseline, 4, and 12 months post-implementation of the intervention, although only baseline data were used in the current 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 4-month period prior to implementation of the study provided by facility staff, medications based on chart data (including medications for depression, anxiety, gastrointestinal problems, seizure, pain including opioids, anemia, hyperlipidemia, diabetes, osteoporosis, allergies, anticoagulation, sedative hypnotics, Parkinson's disease, prostate disease, steroids, antipsychotic agents, 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 zero, one, two, or three of three words. The Mini-Cog was developed as a brief screening tool to identify individuals with dementia. The Mini-Cog has sensitivity ranging from 76% to 99% and specificity ranging from 89% to 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 ADLs (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, interrater reliability was supported based on an intraclass correlation of 0.89 between two observers, and validity was based on correlations with the Functional Inventory Measure (r = 0.97, p < 0.05) (Mahoney & Barthel, 1965). Data were 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: (a) residents' perceptions of health care (four items: e.g., Are you satisfied with the skills of the staff you interact with?); (b) the physical environment (five items: e.g., Do you lack personal space?); (c) relationships with staff (eight items: e.g., Are the staff kind and caring?); and (d) physical and social activities (five 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 3 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; therefore, Day 2 data were used for all analyses.
Descriptive analyses were performed to describe the sample including a t test to describe differences in age and comorbidities between men and women. Differences by gender with regard to function, physical activity, falls, total number of medications, and satisfaction with assisted living as per the study hypothesis were tested using multivariate analysis of variance. Multivariate analysis of variance was used to test the effect of the independent variable (i.e., gender) on a set of two or more dependent variables. Absence of multivariate outliers was checked by assessing Mahalanobis Distances among participants. The critical value for the Mahalanobis 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. Box's M test was used to evaluate if covariance matrices were equal. Box's M was significant (Box's M = 52.85, F = 1.43, p = 0.05); therefore, 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 men and women, chi-square analyses were performed. A p < 0.05 level of significance was used for all analyses.
There were 166 (28%) men and 427 (72%) women in the study with an overall mean age of 88 (SD = 7.19 years). Participants had approximately five (SD = 2) comorbidities and took on average 6.88 (SD = 3.47) medications. Overall, mean RSI subscale scores were high: Health Care Satisfaction = 3.59 (SD = 0.81) of a total score of 4, Physical Environment Satisfaction = 4.35 (SD = 0.93) of a total possible score of 5, Relationships with Staff = 7.09 (SD = 1.27) of a total possible score of 8, and Satisfaction with Activities = 4.19 (SD = 1.28) of a possible score of 5. There was evidence of moderate functional impairment with a mean score of 64.13 (SD = 19.09) on the Barthel Index of a total score of 100 indicating independence. Participants engaged in 43.8 (SD = 76.12) minutes daily of moderate level physical activity based on the MotionWatch 8 recordings. Twenty-five percent of participants experienced at least one fall over the 4 months prior to the start of the study.
Multivariate test results are shown in Table 1. The Pillai-Bartlett trace was significant for gender (F = 2.10, p = 0.02). Women reported higher satisfaction with activities provided in the setting (4.32 [SD = 1.14]) than men (3.85 [SD = 1.51]) (F = 10.28, p = 0.01), and women received slightly more medications than men (7.09 [SD = 3.51] vs. 6.34 [SD = 3.31], respectively) (F = 2.09, p = 0.05). There were no differences with regard to falls, function, physical activity, satisfaction with the physical environment, relationships with staff, or health care.
Multivariate Analysis and Description of Outcomes by Gender
Table 2 provides the frequency of medication use by gender. Across both groups the most commonly prescribed medications included those for osteoporosis, hyperlipidemia, and gastrointestinal problems as well as anticoagulant and antidepressant agents. The rate of use of opioids was low at 4% to 8%, as was the rate of sedative hypnotics at 2% to 4%, anxiolytics at 3% to 9%, and anti-psychotic agents at 9% to 13%. Women were significantly more likely than men to take steroids (36% of women vs. 24% of men, χ2 = 7.22, p = 0.007), medications for osteoporosis (50% of women vs. 34% of men, χ2 = 12.22, p = 0.001), medications for cardiovascular disease (39% of women vs. 29% of men, χ2 = 5.61, p = 0.018), pain medications including opioids (30% of women versus 18% of men, χ2 = 8.67, p = 0.003), anxiolytics (9% of women versus 3% of men, χ2 = 6.16, p = 0.013), and antidepressant agents (45% of women versus 32% of men, χ2 = 8.09, p = 0.004).
Differences in Medication Use By Gender (N = 593)
The findings from the current study provide partial support for the hypothesis that there would be a significant difference between men and women 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 type of some medications given and satisfaction with activities. Women were noted to be more satisfied with activities and to take significantly more medications than men. Higher satisfaction with activities within assisted living settings by women versus men is not surprising given that older women generally tend to enjoy and engage in more social activity than older men (Finkel et al., 2018; Oshio, 2012; Zhang et al., 2017). Conversely, older men 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 high across all these areas, which is consistent with a national survey of resident satisfaction completed by the Assisted Living Federation of America (Burm, 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 men versus women prefer and expand on types of activities needed to improve participation and satisfaction across both genders.
The current findings related to medication use were similar to other studies noting that women used more medications than men (Midão et al., 2018; Morgan et al., 2016; Niclós, Olivar, & Rodilla, 2018; Rozenfeld et al., 2008). The rates of use across men and women were consistent with polypharmacy, defined as taking five or more medications (Viktil, Moger, & Reikvam, 2007), and raises concerns about the risk of potentially inappropriate medications (2019 American Geriatrics Society Beers Criteria® Update Expert Panel, 2019; Herr et al., 2017). For example, the high use of medications for osteoporosis and hyperlipidemia could be questioned given the average age of 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 individuals older than 70 without a significant history of cardiovascular disease (United States Preventive Services Taskforce, 2018).
Women, 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 the current sample than has been seen in some nursing home samples (Fog et al., 2019; Griffioen, Husebo, Flo, Caljouw, & Achterberg, 2019; Sandvik et al., 2016) although the rates were similar to a recent report of nursing homes from Maryland and Pennsylvania (Resnick, Kolanowski, et al., 2019). 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% to 13%) in the current 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 & Medicaid Services, 2017). The sample rates were, however, higher than the rate of 9% reported from nursing home residents in the United Kingdom (Ballard et al., 2018). Although there was not a significant difference between genders with regard to antipsychotic medication use, consistent with prior research (Kamble, Chen, Sherer, & Aparasu, 2008), men tended to be more likely to receive antipsychotic agents than women.
The rate of antidepressant use was similar to that found in other studies among community-dwelling and nursing home residents (Fog et al., 2019; Helvik, Saltyte 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 men and women (Blumstein, Benyamini, Shmotkin, & Lerner-Geva, 2014; Jacob & Kostev, 2016). Generally, the rate of use of sedative hypnotics and anxiolytics was lower in the current assisted living sample than other studies that included community-dwelling and nursing home residents (Fog et al., 2019; Resnick, Kolanowski, et al., 2019). As has been previously noted, however, women were more likely to be receiving anxiolytics. Furthermore, a study of Israeli older adults noted differences in the factors that influence use of anxiolytics between men and women such that age, being unmarried, sleeping problems, and depressive symptoms were significant correlates of use of anxiolytics among men, whereas any life trauma and being married correlated with use of anxiolytics among women (Blumstein et al., 2014). Continued research is needed to test the associations of these factors with use of anxiolytics and 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 men tended to be more physically active and functionally intact than women (Ahmed et al., 2016; Ahmed et al., 2018; Finkel et al., 2018; Ullrich et al., 2019; Zhang et al., 2017), no gender differences were noted in the current 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, 2011).
Although there was no difference in the amount of activity performed between men and women, it has been suggested that there are differences in barriers and facilitators to physical activity between men and women. Several qualitative reports (Kwon et al., 2016; Sandlund et al., 2018) noted that there are differences in barriers to walking for women versus men. Specifically, women describe neighborhood safety concerns, chronic medical conditions, and pain as barriers to physical activity, whereas men note that barriers include laziness or low self-efficacy associated with walking. Facilitators for walking among women were fear of nursing home placement and fear of falling and a desire for weight maintenance or loss. Conversely, men 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 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., 2011), participants in the current study needed some help with ADLs based on the Barthel Index. Despite needing help with ADLs, 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., 2011). Current study participants were noted to engage in a mean of 43.8 (SD = 76.12) minutes of moderate level physical activity daily, whereas participants in another study of physical activity among assisted living residents were noted to spend only 1 minute in moderate to vigorous physical activity (Leung et al., 2017). The current authors 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 >562 counts per minute. This is in contrast to the Actigraph®, which was used in the Leung et al. (2017) 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 men and women in the current sample. Prior research has likewise reported no difference between genders with regard to falls or fall risk (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.
The current 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. Furthermore, the function data may have been biased as it was based on recall of staff who worked with the resident on the day of testing. It is possible that 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 RSI 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 the current study provide some indication that there may be differences among men and women with regard to medication use and satisfaction with activities.
Continued evaluation of gender differences in assisted living settings should be done to help guide how care is provided. Current study findings suggest that deprescribing may be particularly important for women versus men and focusing on expanding activity options to include those preferred by men should be considered in assisted living settings.
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Multivariate Analysis and Description of Outcomes by Gender
|Variable||Mean (SD)||F||p Value|
|Age (years)||88 (8.10)||89 (7.24)||88 (7.19)||1.97||0.16|
|No. of comorbidities||5 (2)||5 (2.01)||5 (2)||0.019||0.89|
|No. of medications||6.34 (3.31)||7.09 (3.51)||6.88 (3.47)||2.09||0.05|
|Resident Satisfaction Indexa|
| Health care (4 items)||3.60 (0.74)||3.58 (0.85)||3.59 (0.81)||0.05||0.81|
| Physical environment (5 items)||4.27 (0.89)||4.38 (0.94)||4.35 (0.93)||1.11||0.29|
| Relationship with staff (8 items)||7.09 (1.23)||7.09 (1.29)||7.09 (1.27)||0.001||0.89|
| Activities (5 items)||3.85 (1.51)||4.32 (1.14)||4.19 (1.28)||10.28||0.01|
|Functionb||65.45 (17.60)||63.58 (19.68)||64.13 (19.09)||0.73||0.39|
|Moderate level physical activityc (min)||41.92 (76.94)||45.67 (75.30)||43.80 (76.12)||0.19||0.67|
| Yes||41 (25)||101 (25)||142 (24)||0.001||0.98|
| No||125 (75)||326 (75)||451 (76)|
Differences in Medication Use By Gender (N = 593)
|Medication/Indication||n (%)||χ2||p Value|
|Men (n = 166)||Women (n = 427)|
|Cholinesterase inhibitors||22 (13)||76 (18)||1.79||0.18|
|Parkinson's disease||9 (5)||26 (6)||0.10||0.76|
|Urinary incontinence||12 (7)||42 (10)||0.98||0.32|
|Steroids||40 (24)||152 (36)||7.22||0.007|
|Osteoporosis||56 (34)||212 (50)||12.22||0.001|
|Cardiovascular||48 (29)||168 (39)||5.61||0.018|
|Diabetes||28 (17)||72 (17)||0.001||0.99|
|Antilipids||76 (46)||175 (41)||1.28||0.29|
|Anticoagulants||88 (53)||191 (45)||3.29||0.07|
|Anemia||24 (15)||53 (12)||0.44||0.51|
|Pain (including opioids)||30 (18)||128 (30)||8.67||0.003|
|Opioids only||6 (4)||32 (8)||3.00||0.08|
|Seizures||32 (19)||86 (20)||0.06||0.81|
|Gastrointestinal||88 (53)||257 (60)||2.25||0.112|
|Anxiolytics||5 (3)||38 (9)||6.16||0.013|
|Antidepressants||53 (32)||191 (45)||8.09||0.004|
|Antipsychotics||21 (13)||38 (9)||1.87||0.171|
|Sedative hypnotics||7 (4)||10 (2)||1.51||0.22|