Practical Geriatrics : Gender Sensitivity in Health Care for Elderly Men and Women

Gender can be viewed not only as an attribute of individuals but as a system of meanings shaped by culture (1). Many people, including providers of health and mental health care, still use the term "sex" when referring to gender. This use of the term can itself be a reflection of gender insensitivity, because many stereotypes and biases have historically been associated with being of the male or female sex.

Sex has primarily biological connotations, whereas gender refers to a broad spectrum of biopsychosocial attributes that can cross the stereotyped boundaries between male and female. These boundaries were more prevalent in the past, but they still linger in many organizational systems and relationships. Gender roles have changed from being primarily determined by men in power to being more self-determined. Networking and collaboration within and between genders and equal authority and reward at home and in the work environment are progressively more valued.

The capacity for autonomous thinking, clear decision making, and responsible action are attributes of each gender. The distinctive qualities of capacity for empathy, compassion , intimacy, and attachment have been found to be especially prevalent in women (2,3,4,5,6). These attributes lead to women's developing different priorities in decision making compared with men, who place more emphasis on separation and individuation, hierarchy of authority, and competition. Over the last 20 years mentoring and role modeling by women in leadership roles have become more highly valued, as has companionship between women throughout the life cycle.

The aging population is experiencing these changes across generations. However, in their own lives, elderly persons are primarily experiencing the sequelae of the attitudes and behaviors that have prevailed during their lifetime. As they become older, women become members of a majority that is increasingly disadvantaged economically, medically, and emotionally. Clinicians' sensitivity to gender issues can be greatly enhanced by realistic knowledge about differences between the situations and conditions that affect elderly men and those that affect elderly women. At the same time, clinicians should keep an open mind about individual variations in coping mechanisms and support systems.

This column addresses gender-related variation in late life in the areas of demographic characteristics, psychiatric disorders and gender-specific diseases, and the risks and benefits of screening for and treating these disorders.

Demographic characteristics

The lengthening of lifespan during this century has been particularly striking. At the turn of the century, only 39 percent of births survived till age 65, whereas at the end of this century, 86 percent are expected to survive to age 65, and 58 percent to age 80 (7). The current ratio of men to women is 69 to 100 at age 65, and 36 to 100 by age 85 (8).

Most older men live in family settings; most older women live alone. Seventy-five percent of nursing home residents are women age 65 and older. Women make up 72 percent of poor elderly people, and twice as many African-American women as white women experience poverty (8). When men die, they are three times as likely as women to leave an impoverished spouse. More women than men Medicare enrollees lack supplemental insurance policies (9).

Grandparenting becomes an important role in late life. By the year 2000, overall 67 percent of 30-year-olds will have a living grandmother, and their children will have a living great-grandmother; only 27 percent of 30-year-olds will have a living grandfather (10).

The ratio of those who need care and those who do the caregiving will continue to change markedly. Fifty percent of women in the early part of this century had four or more children. By the 1980s this proportion had decreased by 25 percent. Twenty percent of baby boomers have no children, and 25 percent have only one child. Thus the size of the network of family caregivers will decline markedly by the time the 76 million baby boomers become senior boomers in 2010 to 2028. Wives, mothers, daughters, and daughters-in-law, many of whom are now in the workforce, continue to take on the additional role of primary caregiver whenever the need arises in the family (11). Only a few women in the generation whose main role in life was that of caregiver have been rewarded for their dedicated efforts.

The aware, concerned clinician can work toward reducing the negative effects of gender-related differences by recognizing the social inequities faced by aging women, acknowledging their contributions to their families and others, helping aging women improve their self-esteem, and empowering those who are able to modify their role in life. Clinicians should obtain a brief history of family relationships, life roles, supports, and companionship, as well as financial status, all of which have a considerable bearing on health status.

Psychiatric and physical disorders

Differences in psychopathology between men and women and the role of female hormones in increasing or decreasing susceptibility to certain disorders have been studied (12). Unipolar depression and dysthymia are twice as common among women than among men, and women have more frequent recurrences of depression in late life. Social role and personality, as well as hormonal variations, have been implicated to explain these findings (12). Generalized anxiety, panic disorders, phobias, and posttraumatic stress disorder occur with greater frequency among women than among men. Cyclic variations in levels of circulating estrogen and progesterone have been implicated in women's increased vulnerability to anxiety disorders (12).

Caucasian men age 65 and older have the highest suicide rate in the U.S., and the suicide rate of Caucasian men between age 80 and 84 has been rising (13). Some suicide prevention centers and other programs are planning to increase awareness of risk factors in this age group and to provide peer counseling.

After adjustment for longevity, data show that more women than men suffer from Alzheimer's disease. Age-associated memory impairment is difficult to distinguish from the early stages of progressive degenerative brain disease. Therefore, assessment at half-year intervals is recommended. Estrogen has been found to delay onset of Alzheimer's disease and even to improve memory among some patients with the disorder.

Schizophrenia that first occurs in late life is more common among women than men. Schizophrenia with early-life onset occurs later among women than among men. It has been hypothesized that estrogen protects against psychosis (12). Although considerably more men than women suffer from alcohol-related disorders, women with alcohol dependence are more likely to develop medical consequences, and they have higher rates of mortality at a younger age (14). Androgen enhances alcohol metabolism in the liver and may allow more efficient elimination of alcohol that could contribute to earlier alcohol dependency in men (14); women may have a greater absorption of alcohol and thus greater risk of toxicity. More women start to abuse alcohol for the first time in late life (15).

Screening and treatment of physical conditions

Estrogen replacement therapy after menopause can improve immediate and delayed verbal memory, help preserve the ability to learn new material, and enhance mood (16). The Multicenter Women's Health Initiative sponsored by the National Institutes of Health, with data analysis due in the year 2007, will shed more light on the risks associated with estrogen replacement therapy and hormone replacement therapy. Possible risks include uterine and breast cancer; potential benefits include prevention of osteoporosis, cardiovascular disease, and dementia.

Hormone replacement therapy for women who have not had a hysterectomy includes progesterone to diminish the risk of uterine cancer, although synthetic progesterone dampens mood. Hormone replacement therapy can alleviate hot flashes, dry skin and mucous membranes, insomnia, and incontinence. The favorable effects of estrogen on bone density, serum lipids, and brain tissue motivate many women to remain on hormone replacement therapy notwithstanding the possibility of increased risk of breast cancer. Increase in fibrocystic breast tissue during hormone replacement therapy causes discomfort and makes mammograms more difficult to read. Whether and when postmenopausal women should start on hormone replacement therapy and how long they should continue remain unanswered questions.

Considering the increasing prevalence of breast cancer in developed countries, partly because of higher lifetime exposure to estrogen, adding more estrogen after menopause carries a serious risk of bringing breast cancer to epidemic proportions. No preventive measures for breast cancer are available, no reliable biological markers for the disease have yet been found, and more sensitive digital mammography is still in the research phase. Thus primary care physicians who treat elderly women on hormone replacement therapy need to include careful, fastidious breast examinations and extensive education in their clinical routines. Guidelines from the American College of Physicians and the American College of Obstetricians and Gynecologists are available and are under constant review.

To allow a patient to be a truly informed participant in decision making about treatment of breast cancer, the patient needs to be educated about what is in store when a malignant growth of more than 2 cm is found and when an infiltrating tumor with or without positive lymph nodes is found at surgery.

Because of the need for rapid decision making once breast cancer is diagnosed, few women have the opportunity to become well informed about the potential impact of treatments on the quality of life. Most enter into a stream of statistics of recurrences and survival data. Standardized treatment routines for breast cancer involving surgery, chemotherapy, and radiation tend to strip away individuality (17). Pharmacokinetic variations among women over age 50 have not yet been studied and are not taken into consideration in the dosing of chemotherapy with all its deleterious side effects. How the nonsteroidal antiestrogen tamoxifen, used in the treatment of certain stages of breast cancer, affects mood and cognitive function has not yet been investigated.

Screening and treatment of prostate cancer in men are controversial issues. Sequelae of treatment such as impotence and incontinence are receiving considerable attention. The majority of men age 50 and over with abnormal findings on digital rectal examination or an abnormal prostate-specific antigen (PSA) level will not develop prostate cancer but will undergo transrectal ultrasound and transrectal needle biopsy of the prostate.

The American Cancer Society, the American College of Physicians, and the American Academy of Family Physicians each have guidelines for screening for prostate cancer (18). The American Cancer Society consensus-based screening guideline recommends that digital rectal examination and the PSA should be offered annually beginning at age 50 to men who have at least a ten-year life expectancy and to younger men who are at risk (18). The importance of patient information about potential risks and benefits of early detection is emphasized in each guideline. Views against routine annual screening seem to originate in the fact that many men live for years with asymptomatic prostate cancer and are found at autopsy to have died of other causes.

Research on quality-of-life issues for women treated for breast cancer in late life is extremely sparse (19), while quality-of-life studies of men with prostate cancer are more readily available.

The sensitive and knowledgeable clinician needs to be able to assess the individual patient's perception of and reaction to a disease and how the disease and treatment affect the quality of life of the patient and his or her family. Patient education materials should be updated frequently and should be gender-, culture-, and age-sensitive to help clinicians and patients make well-informed, personally appropriate decisions.

Summary

Clinicians function in an environment of protocols and guidelines. In developing requirements for reimbursement, the Health Care Financing Administration and the for-profit health care industry often overlook the time involved in forming sound clinical judgments and establishing and maintaining confidential and trusting doctor-patient relationships. Clinicians can best serve their patients by being attentive to the complexities of aging and gender while remaining conscious of time- and cost-efficiencies, keeping informed of the latest research, and orienting treatment toward optimal outcomes.

Dr. Goldstein, the editor of this column, is clinical associate professor in the department of psychiatry and director of the division of geriatric psychiatry at the State University of New York at Buffalo School of Medicine and Biomedical Sciences. Dr. Griswold is clinical assistant professor in the department of family medicine at the school. Address correspondence to Dr. Goldstein at the Erie County Medical Center, 462 Grider Street, Buffalo, New York 14215.