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Are there still sex differences in the functioning of the elderly?

Abstract

Introduction:

Sex is one of the demographic characteristics that better differentiates the independence of the elderly, despite this distinction not being consensual.

Objective:

To know the differences in functioning associated with sex in elderly people aged ≥ 65 years according to the International Classification of Functioning, Disability, and Health (ICF).

Methods:

This was an analytical and cross-sectional observational study with a sample of 451 subjects. The instruments were a sociodemographic questionnaire identical to a ICF checklist and the Biopsychosocial Assessment Method. The student t, Mann-Whitney, chi-square, and Spearman correlation tests were used considering p < 0.05.

Results:

The average age was between 79.5 ± 7.5 years with a female prevalence (62.1%). Of the 43 variables studied, sex differences were found in 17 (39.5%). In the personal factors, women showed greater vulnerability in conjugality (p ≤ 0.001), cohabitation (p = 0.037), and economic income (p = 0.002). Nonetheless, they showed healthier behaviors in all health-related habits. As for environmental factors and body functions, greater fragility was once again observed in women: the need for assistive devices (p ≤ 0.001) and urinary incontinence (p = 0.021). In activities/participation, differences were found in mobility, where women experienced more restrictions, whereas men were more dependent on washing/drying clothes in domestic life (p = 0.022).

Conclusion:

Women are more unprotected in social and economic areas, while men showed more vulnerability in habits related to health. These differences are linked to demographic issues related to longevity, cultural differences, and socialization, and differences regarding activities/participation tend to dilute between sexes.

Keywords:
Elderly; Frailty; ICF; Sex

Resumo

Introdução:

O sexo é das caraterísticas demográficas que mais diferencia a independência dos idosos, apesar dessa distinção não ser consensual.

Objetivo:

Conhecer as diferenças da funcionalidade associadas ao sexo, de acordo com a Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) em idosos com idade ≥ 65 anos.

Métodos:

Estudo observacional, analítico e transversal com uma amostra de 451 indivíduos. Os instrumentos utilizados foram um questionário sociodemográfico idêntico à checklist da CIF e o Método de Avaliação Biopsicossocial. Utilizaram-se os testes de T-Student, Mann-Whitney, Qui-Quadrado e Correlação de Spearman, considerando-se p < 0,05.

Resultados:

A média de idade foi de 79,5 ± 7,5 anos, observando-se uma prevalência feminina (62,1%). Das 43 variáveis estudadas, foram encontradas diferenças entre os sexos em 17 (39,5%). Nos fatores pessoais, as mulheres apresentaram maior vulnerabilidade na conjugalidade (p ≤ 0,001), na coabitação (p = 0,037) e no rendimento econômico (p = 0,002). Em todos os hábitos relacionados com a saúde, contudo, revelaram comportamentos mais saudáveis. Nos fatores ambientais e nas funções do corpo, observou-se novamente maior fragilidade nas mulheres: na necessidade de dispositivos de auxílio (p ≤ 0,001) e na incontinência urinária (p = 0,021). Nas atividades/participação, as mulheres apresentaram maior restrição na mobilidade e os homens na vida doméstica (lavar/secar roupa p = 0,022).

Conclusão:

As mulheres apresentam-se mais desprotegidas nas dimensões social e econômica, enquanto os homens manifestam hábitos de saúde mais vulneráveis. Estas diferenças estão ligadas às questões demográficas de longevidade e às diferenças culturais e de socialização. As diferenças nos domínios das atividades/participação tendem a diluir-se entre os sexos.

Palavras-chave:
Idoso; Fragilidade; CIF; Sexo

Introduction

Along with age, sex is one of the demographic characteristics with the greatest weight in differentiating the functioning of the elderly, albeit this is not unanimous in the literature. Despite most studies indicating an advantage for men,11 Boerma T, Hosseinpoor AR, Verdes E, Chatterji S. A global assessment of the gender gap in self-reported health with survey data from 59 countries. BMC Public Health. 2016;16:675. DOI
DOI...

2 Serrano-Alarcón, Perelman J. Ageing under unequal circumstances: a cross-sectional analysis of the gender and socioeco-nomic patterning of functional limitations among the Southern European elderly. Int J Equity Health. 2017;16(1):175. DOI
DOI...

3 Jacob ME, Marron MM, Boudreau RM, Odden MC, Arnold AM, Newman AB. Age, race, and gender factors in incident disability. J Gerontol A Biol Sci Med Sci. 2018;73(2):194-7. DOI
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-44 Carmona-Torres JM, Rodríguez-Borrego MA, Laredo-Aguilera JA, López-Soto PJ, Santacruz-Salas E, Cobo-Cuenca AI. Disability for basic and instrumental activities of daily living in older individuals. PLoS One. 2019;14(7):e0220157. DOI
DOI...
the differences tend to fade at older ages.55 Oliveira A, Nossa P, Mota-Pinto A. Assessing functional capacity and factors determining functional decline in the elderly: a cross-sectional study. Acta Med Port. 2019;32(10):654-60. Full text link
Full text link...
,66 Fontes AP, Botelho MA, Fernandes AA. A funcionalidade dos mais idosos (≥75 anos): conceitos, perfis e oportunidades de um grupo heterogêneo. Rev Bras Geriatr Gerontol. 2013;16(1): 91-107. DOI
DOI...

According to the World Health Organization (WHO), functioning is an interactive and integrative multidimensional construct in which individual dimensions (biopsychosocial) and contextual, environmental, and personal factors interact, whose operationalization is described in the conceptual model of the International Classification of Functioning, Disability, and Health (ICF).77 World Health Organization. International Classification of Functioning, Disability and Health (ICF). Genebra: WHO; 2001. Full text link
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Sex is a personal factor, although this component has not yet been codified in the ICF. Because of its broad social and cultural variability, its variables should always be considered when assessing functioning because those that can be modifiable exceed their importance as determinants of health status as they can be considered a change to the genesis of disability, and above all, by the possibility of being considered the genesis of the intervention.

Research on the differences between men and women has gone beyond epidemiological knowledge. Its importance and conclusions should focus predominantly on the possibility of reducing social and cultural differences, namely at the level of social institutions, identity, and power relations, the results of which will be projected onto health and functioning.88 Fernandes AA, Burnay R. Homens saudáveis, mulheres doentes? Um estudo sobre a esperança de vida e a saúde da população portuguesa. Rev Bras Pesq Saude. 2019;21(2):17-28. Full text link
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,99 Zheng Z, Gao J, Yang Y. The enigma of gender differences in an environment-behavior-health model of elderly people: the choice between individually and sociality. Int J Environ Res Public Health. 2020;17(10):3483. DOI
DOI...

Dessa forma, apesar de o sexo ser um fator pessoal não modificável, a determinação da sua influência na funcionalidade/incapacidade na população idosa deve continuar a ser investigada, pois poderá ser um contributo para intervenções mais sistematizadas ao nível dos serviços, sistemas e políticas.

Thus, although sex is a non-modifiable personal factor, determining its influence on functioning/disability in the elderly population must continue to be investigated, as it may contribute to more systematized interventions at the service, system, and policy levels. Given this scenario, this study sought to determine the differences in functioning associated with sex according to the ICF in elderly people aged ≥65 years.

Methods

This is an observational, analytical, cross-sectional study whose sample includes elderly people aged 65 years or older and who previously lived at home and were later admitted to the convalescence units and rehabilitation units of the National Network of Continuous Integrated Care (Rede) in the Algarve region (Portugal) after an acute episode of disease, injury, or trauma.

The data were collected within the first 48 h of entry into the Rede and related exclusively to the pre-morbidity condition, and information was collected on the different components and domains of functioning. The study was previously authorized by the Ethics Committee of the Regional Health Administration of Algarve (reference 013/10 DEP of 15/10/2010); informed consent was obtained from all participants.

The sampling method was non-probabilistic, and the instruments used were a questionnaire for sociodemographic characterization with a structure identical to the ICF checklist 1010 World Health Organization. ICF Checklist: version 2.1a, Clinician Form for International Classification of Functioning, Disability and Health. 2003 [cited 2020 Aug 29]. Available from: https://tinyurl.com/345u3p4d
https://tinyurl.com/345u3p4d...
and the Biopsychosocial Assessment Method (BAM) developed by Botelho.1111 Botelho MA. Autonomia funcional em idosos: caracterização multidimensional em idosos utentes de um centro de saúde urbano. Porto: Laboratórios Bial; 2002. 197 p.

The BAM is a structured, standardized, screening-type assessment and biopsychosocial classification of adults and is adopted at the national level by the Network.1111 Botelho MA. Autonomia funcional em idosos: caracterização multidimensional em idosos utentes de um centro de saúde urbano. Porto: Laboratórios Bial; 2002. 197 p. It allows biopsychosocial and functional states to be characterized and describe and detect functioning disorders. As the name indicates, it contains three assessment areas with 12 domains that group 19 variables, totaling 56 questions. The scoring is done on a scale that can have up to four degrees depending on the characteristics of the variables, which enable the different domains to be scored, thus creating the individual’s functional profile. The BAM was subjected to connecting with the ICF,1212 Fontes AP, Botelho MA, Fernandes AA. A biopsychosocial evaluation method and the International Classification of Functioning, Disability and Health (ICF). Educ Gerontol. 2014; 40(9):686-99. DOI
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which revealed a good conceptual structure and significant concepts and presented itself as a comprehensive and integrating instrument to assess functioning, as recommended by the WHO.

The variables of the domains locomotion, physical autonomy, and instrumental autonomy, which in the instrument are scored in four levels, were dichotomized into “incapable/dependent” (0 = incapable and 1 = dependent on others) and “autonomous/independent” (2 = autonomous with auxiliary means and 3 = independent). The remaining variables followed the original values.1111 Botelho MA. Autonomia funcional em idosos: caracterização multidimensional em idosos utentes de um centro de saúde urbano. Porto: Laboratórios Bial; 2002. 197 p. A total of 43 variables were studied and divided by the different ICF components and domains (Table 1).

Table 1
Components, domains, and variables of the study according to the International Classification of Functioning, Disability and Health (ICF)

Personal factors have not been classified by the WHO so far, although they should be included in any assessment/intervention process in order to know their contribution and influence on functioning. They are the particular history of an individual’s life and lifestyle and encompass the characteristics that are not part of a health condition or state.7 For organization and similarity, personal factors were grouped into two dimensions: social, cultural, and economic aspects and health-related behaviors and events.

Statistical analysis

Categorical variables were analyzed by absolute and relative frequencies and numerical variables by central tendency and dispersion measures. The comparative analyses between sexes were performed using the Mann-Whitney test for categorical variables and the Student t-test for independent samples for numerical variables. The chi-square test was used to analyze the independence between sex and the variables under study, and Spearman’s correlation coefficient was used to evaluate the association level. The statistical analysis considered a significance level of 0.05.

Results

The sample consisted of 451 individuals, with a mean age of 79.48 ± 7.46 years and a female prevalence (62.1%). The mean age of women was relatively higher than the men (p = 0.037; 80.5 ± 7.38 to 78.5 ± 7.52 years).

Of the 43 variables studied, sex differences were found in 17 (39.5%). Nineteen variables included in the personal factors were studied, with differences occurring in 11 (57.9%), namely in conjugality (p ≤ 0001) and cohabitation (p = 0.037), with women being lonelier in both situations, and also in economic income (p = 0.002), with more unfavorable values for women. However, women showed healthier behaviors in all health-related habits. The independence regarding sex had an identical behavior to the differences found in the comparison between men and women, except for tobacco consumption (PPY; x2 = 0.211) and the number of falls (x2 = 0.023). The intensity of the association found ranged from weak to moderate: from rS = 0.098 (with whom you live) to rS = 0.572 (alcohol consumption). The distribution of the sample in relation to personal factors and the differences found between sexes and their association is listed in Tables 2.1 and 2.2.

Table 2.1
Descriptive and inferential statistics of the variables of the personal factors component: social, economic, and cultural factors

Table 2.2
Descriptive and inferential statistics of the variables of the personal factors component: health-related behaviors and events

In the environmental factors, women showed more need for assistive devices (p ≤ 0.001), and the distribution of “who helps with activities” also revealed differences (p ≤ 0.001): women mainly receive help from their children, while men receive it from their spouses. Independence concerning sex had an identical behavior to the differences found in the comparison between men and women, and the intensity of the association for both variables in this component was weak. The results referring to environmental factors are presented in Table 3.

Table 3
Descriptive and inferential statistics of the variables of the environmental factors component

The differences found in body functions occurred in urinary incontinence (p = 0.021), where women showed a higher frequency in this dysfunction; nonetheless, sex was not associated with the presence of this condition. The results concerning this component are listed in Table 4.

Table 4
Descriptive and inferential statistics of the variables of the body functions component

Of the 20 variables of activities/participation, differences were found in three (15%): in mobility, women were more vulnerable (walking on the street p = 0.034 and using transportation p = 0.004); in domestic life, men showed more dependence in the variable washing/drying clothes (p = 0.022). Regarding the independence of the variables, the behavior was identical to the differences found in the comparison between men and women, and the intensity of the association ranged from weak to moderate. The distribution of the sample regarding the activities/participation variables and the differences found between sexes and their association are presented in Table 5.

Table 5
Descriptive and inferential statistics of the variables of the activities/participation component

Discussion

The most significant differences between men and women occurred in the personal factors component. This result corroborates the literature, which emphasizes the importance of studying social, economic, and cultural asymmetries as determinants of health status and functioning in populations because, when modifiable, they can exert an equal or greater power than those related to biological and physiological differences.88 Fernandes AA, Burnay R. Homens saudáveis, mulheres doentes? Um estudo sobre a esperança de vida e a saúde da população portuguesa. Rev Bras Pesq Saude. 2019;21(2):17-28. Full text link
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The “widowed/single/separated” conjugality was higher among women due to their greater longevity, a situation that tends to progress with advancing age mainly because of widowhood.

No differences were found in schooling, with a meager rate in the total sample (over 90% of the individuals had no schooling or schooling of 4 years or less), although the 2011 Census reported that the illiteracy rate for women is roughly twice that of men (6.8 against 3.5%). Although the 2011 Census findings revealed an overall decline in the illiteracy rate from 9.0 to 5.2% compared to 2001, Portugal still has a high proportion of people with no schooling or poor schooling skills in older individuals. This is a challenging aspect in developing educational policies for future elderly generations, since the extension of schooling is a determinant that will bring benefits to health literacy and, consequently, to the population’s health,1313 Fernandes AA. Determinantes da mortalidade e da longevidade: Portugal numa perspectiva europeia (UE15, 1991-2001). Anal Soc. 2007;42(183):419-43. Full text link
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while reducing the burden on health services.22 Serrano-Alarcón, Perelman J. Ageing under unequal circumstances: a cross-sectional analysis of the gender and socioeco-nomic patterning of functional limitations among the Southern European elderly. Int J Equity Health. 2017;16(1):175. DOI
DOI...

The percentage of elderly living alone at home was higher among women, which must be related to the greater longevity of women, which, precipitating their widowhood, makes them also live more isolated. Nevertheless, the percentage of individuals spending over 8 h alone was higher than individuals living alone (32.8 and 29.7%, respectively), suggesting that even those who live with others spend a lot of time alone; it is likely the widowed elderly who live with their children spend much of their time working away from home.

Women had more religious belief and worship practice, although the latter in a markedly lower value (from 90.7 to 58.2%). The interest and number of studies on religiosity and spirituality in the elderly have grown exponentially in the last few years, with numerous studies on their association with functioning, well-being, participation, and quality of life, both in the context of health and disease. Religious belief and practices are common in Portugal, especially among older age groups and women. Despite inter- and intra-generational declines in religious practice, the religiosity of the Portuguese remains high in practices, attitudes towards the church, and people’s self-perception as religious.1414 Menéndez MA. Religiosidade e valores em Portugal: comparação com a Espanha e a Europa católica. Anal Soc. 2007;42(184):757-87. Full text link
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Spiritual development and religiosity tend to increase with aging, and some aspects of spirituality intensify and are associated with this process. In essence, spirituality in later life is about finding a core meaning in life and applying that meaning to one’s relationship with God and others;1515 Manning LK. Spirituality as a lived experience: exploring the essence of spirituality for women in late life. Int J Aging Hum Dev. 2012;75(2):95-113. DOI
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women usually tend to be more religious in research. This conclusion is argued by the fact that many of the social aspects of religion contain feminine traits, such as obedience and caring for others. Another reason for this distinction is socialization: women tend to have more extensive social ties and social support systems, both within the church and in other secular settings, making them more participatory and collective.99 Zheng Z, Gao J, Yang Y. The enigma of gender differences in an environment-behavior-health model of elderly people: the choice between individually and sociality. Int J Environ Res Public Health. 2020;17(10):3483. DOI
DOI...
Worship practice revealed a lower adherence on the part of the sample members, and this is probably because they have difficulty traveling to places of worship or, generically speaking, because a global decrease in their participation has been observed.

Research is unanimous in referring to the lower economic income of elderly women, and this is derived from the precariousness of their schooling and professional specialization,66 Fontes AP, Botelho MA, Fernandes AA. A funcionalidade dos mais idosos (≥75 anos): conceitos, perfis e oportunidades de um grupo heterogêneo. Rev Bras Geriatr Gerontol. 2013;16(1): 91-107. DOI
DOI...
,88 Fernandes AA, Burnay R. Homens saudáveis, mulheres doentes? Um estudo sobre a esperança de vida e a saúde da população portuguesa. Rev Bras Pesq Saude. 2019;21(2):17-28. Full text link
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salthough in this study, neither schooling nor profession was different concerning sex. The elderly, especially women, are one of the most vulnerable groups to poverty due to the low value of their pensions, a vulnerability that has been accentuated by the current economic and social situation.88 Fernandes AA, Burnay R. Homens saudáveis, mulheres doentes? Um estudo sobre a esperança de vida e a saúde da população portuguesa. Rev Bras Pesq Saude. 2019;21(2):17-28. Full text link
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,1313 Fernandes AA. Determinantes da mortalidade e da longevidade: Portugal numa perspectiva europeia (UE15, 1991-2001). Anal Soc. 2007;42(183):419-43. Full text link
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,1616 Lima ALB, Espelt A, Bosque-Prous M, Lima KC. Gender differences in disability among older adults in the context of social gender and income inequalities: 2013 Brazilian Health Survey. Rev Bras Epidemiol. 2020;23:e200002. DOI
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The breakdown of inequality indices confirms the vulnerability of the elderly population to poverty, as well as more disadvantaged situations in terms of health status and education levels, also verifying a significant disparity between sexes, to the disadvantage of women, especially considering the elderly population in the first decile of poverty.88 Fernandes AA, Burnay R. Homens saudáveis, mulheres doentes? Um estudo sobre a esperança de vida e a saúde da população portuguesa. Rev Bras Pesq Saude. 2019;21(2):17-28. Full text link
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,1313 Fernandes AA. Determinantes da mortalidade e da longevidade: Portugal numa perspectiva europeia (UE15, 1991-2001). Anal Soc. 2007;42(183):419-43. Full text link
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These data reflect the history of accessibility to schooling in Portugal in the first decades of the last century, and this is materialized primarily in women.

In the same way that overall low schooling was observed, a poor professional differentiation was also found (77.4% of individuals with unskilled occupations). Education is undoubtedly inseparable from qualification and professional differentiation, the manifestation of which is observed in the older generations and, above all, if we consider the percentage of those individuals linked to the primary sector. The socioeconomic status reflected by education, income, and professional activity must be regarded as determinants of longevity and mortality;88 Fernandes AA, Burnay R. Homens saudáveis, mulheres doentes? Um estudo sobre a esperança de vida e a saúde da população portuguesa. Rev Bras Pesq Saude. 2019;21(2):17-28. Full text link
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this is because, in addition to the important and intricate relationship they establish among themselves, they project the possibility of access to health care and relate to individuals’ health condition and functioning.22 Serrano-Alarcón, Perelman J. Ageing under unequal circumstances: a cross-sectional analysis of the gender and socioeco-nomic patterning of functional limitations among the Southern European elderly. Int J Equity Health. 2017;16(1):175. DOI
DOI...
,44 Carmona-Torres JM, Rodríguez-Borrego MA, Laredo-Aguilera JA, López-Soto PJ, Santacruz-Salas E, Cobo-Cuenca AI. Disability for basic and instrumental activities of daily living in older individuals. PLoS One. 2019;14(7):e0220157. DOI
DOI...
,1616 Lima ALB, Espelt A, Bosque-Prous M, Lima KC. Gender differences in disability among older adults in the context of social gender and income inequalities: 2013 Brazilian Health Survey. Rev Bras Epidemiol. 2020;23:e200002. DOI
DOI...

The perception of physical and mental health status is a recommended indicator in population health monitoring; it is recognized as a predictor of morbidity, functional decline, and mortality55 Oliveira A, Nossa P, Mota-Pinto A. Assessing functional capacity and factors determining functional decline in the elderly: a cross-sectional study. Acta Med Port. 2019;32(10):654-60. Full text link
Full text link...
,1616 Lima ALB, Espelt A, Bosque-Prous M, Lima KC. Gender differences in disability among older adults in the context of social gender and income inequalities: 2013 Brazilian Health Survey. Rev Bras Epidemiol. 2020;23:e200002. DOI
DOI...
as well as for its relationship with health-related quality of life.88 Fernandes AA, Burnay R. Homens saudáveis, mulheres doentes? Um estudo sobre a esperança de vida e a saúde da população portuguesa. Rev Bras Pesq Saude. 2019;21(2):17-28. Full text link
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The perception of mental health was more positive than that of physical health, and in both, men showed more positive values, although without significant differences. Most studies show a more unfavorable perception for women, and this is associated with their greater longevity and the higher presence of chronic conditions.11 Boerma T, Hosseinpoor AR, Verdes E, Chatterji S. A global assessment of the gender gap in self-reported health with survey data from 59 countries. BMC Public Health. 2016;16:675. DOI
DOI...
,1616 Lima ALB, Espelt A, Bosque-Prous M, Lima KC. Gender differences in disability among older adults in the context of social gender and income inequalities: 2013 Brazilian Health Survey. Rev Bras Epidemiol. 2020;23:e200002. DOI
DOI...

Overall, in this study, the female sex showed healthier habits or behaviors regarding consuming meals, smoking, and alcohol. The average number of meals per day corresponds to the four main daily meals, and a high number of meals per day is one of the variables contemplated in healthy eating habits and balanced diets, constituting a reference in the screening of risk groups and functioning.1717 Sugiura Y, Tanimoto Y, Imbe A, Inaba Y, Sakai S, Shishikura K, et al. Association between functional capacity decline and nutritional status based on the nutrition screening initiative checklist: a 2- year cohort study of Japanese community dwelling elderly. PLoS One. 2016;11(11):e0166037. DOI
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This factor, along with the quality of nutrients, can improve chronic disease control, health, and functioning at any age. Culturally, women are more associated with food acquisition and preparation, which in itself predisposes them to a greater tendency to consume more meals.

Regarding tobacco consumption, this study found low values (15.5% for the total sample); its consumption tends to decrease with age, being almost nonexistent in females. For cultural reasons and regarding older age groups, tobacco consumption is more common among males and more educated individuals, with the latter having to add the economic superiority that facilitates its acquisition. Nonetheless, although significant differences were observed in the number of PPY, this proved not to be correlated to sex.

In Portugal and the older generations, alcohol consumption is substantially linked to males due to cultural, economic, and socialization issues, as evidenced by the associated diseases and mortality. We also concluded that alcohol consumption was higher than tobacco consumption (28.8% vs. 15.5%), which is not unrelated to the fact that Portugal has important wine production as it is rooted in its consumption in the main meals.

Over half of the individuals reported requiring help in performing daily activities, especially more complex ones, although with no differences in sex. As we will see later in the analysis of the different activities, the differences in functioning between sexes were basically related to mobility/locomotion. This may be why no sex differences were found in the need and type of help to carry out activities.

Although the number of falls was not significantly different between men and women, the sequelae observed were higher in women. The literature usually refers that women fall more often,1818 Elias Filho J, Borel WP, Diz JBM, Barbosa AWC, Britto RR, Felício DC. Prevalence of falls and associated factors in community-dwelling older Brazilians: a systematic review and meta-analysis. Cad Saude Publica. 2019;35(8):e00115718. DOI
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although this differentiation tends to disappear at more advanced ages,66 Fontes AP, Botelho MA, Fernandes AA. A funcionalidade dos mais idosos (≥75 anos): conceitos, perfis e oportunidades de um grupo heterogêneo. Rev Bras Geriatr Gerontol. 2013;16(1): 91-107. DOI
DOI...
as previously reported herein. The justification for the higher number of sequelae in women may be their greater frailty and prevalence of sarcopenia and osteoporosis,1818 Elias Filho J, Borel WP, Diz JBM, Barbosa AWC, Britto RR, Felício DC. Prevalence of falls and associated factors in community-dwelling older Brazilians: a systematic review and meta-analysis. Cad Saude Publica. 2019;35(8):e00115718. DOI
DOI...
,1919 Ek S, Rizzuto D, Fratiglioni L, Calderón-Larrañaga A, Johnell K, Sjöberg L, et al. Risk factors for injurious falls in older adults: the role of sex and length of follow-up. J Am Geriatr Soc. 2019;67(2):246-53. DOI
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but also, as observed in our study, it may be linked to difficulties in mobility and marital status. Indeed, impairment in gait dynamics (e.g., changes in direction and speed) leads to more severe sequelae after falls.55 Oliveira A, Nossa P, Mota-Pinto A. Assessing functional capacity and factors determining functional decline in the elderly: a cross-sectional study. Acta Med Port. 2019;32(10):654-60. Full text link
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Nonetheless, some studies suggest that the presence of a partner or cohabitation may be a protective factor for this risk55 Oliveira A, Nossa P, Mota-Pinto A. Assessing functional capacity and factors determining functional decline in the elderly: a cross-sectional study. Acta Med Port. 2019;32(10):654-60. Full text link
Full text link...
,1919 Ek S, Rizzuto D, Fratiglioni L, Calderón-Larrañaga A, Johnell K, Sjöberg L, et al. Risk factors for injurious falls in older adults: the role of sex and length of follow-up. J Am Geriatr Soc. 2019;67(2):246-53. DOI
DOI...
based on the support and supervision they can provide.

About two-thirds of the individuals (65.6%) reported needing an assistive device, and this use was higher among women. The ease of access and technological development of assistive devices increased their use, allowing the elderly population to maintain higher and longer levels of independence; the use of visual, hearing, and walking aids increases with age due to the structural and physiological changes associated with them. Considering that in the present sample women were older and had more difficulties in locomotion, this may explain their greater need. Some studies also specify a higher prevalence of women associated with a greater demand for health care, which increases the opportunity to use these devices.11 Boerma T, Hosseinpoor AR, Verdes E, Chatterji S. A global assessment of the gender gap in self-reported health with survey data from 59 countries. BMC Public Health. 2016;16:675. DOI
DOI...
,2020 Vela C, Samson E, Zunzunegui MV, Haddad S, Aubin MJ, Freeman EE. Eye care utilization by older adults in low, middle, and high income countries. BMC Ophthalmol. 2012; 12:5. DOI
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The need for help in performing activities is mainly provided by children (34.0%) in the case of women and by spouses (30.9%) for men. Family support corresponded to 80.9% of the cases, while institutional support was observed in 5.3% of the situations. The literature is unanimous in recognizing that the role of the primary informal caregiver is fundamentally linked to women,2121 Hirata H. Care work: a comparison of Brazil, France and Japan. SUR 24. 2016;13(24):53-63. Full text link
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22 Giacomin KC, Oliveira Duarte YA, Camarano AA, Pires Nunes D, Fernandes D. Cuidado e limitações funcionais em atividades cotidianas - ELSI-Brasil. Rev Saude Publica. 2018;52(Supl 2):9s. DOI
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-2323 Verbakel E. How to understand informal caregiving patterns in Europe? The role of formal long-term care provisions and family care norms. Scand J Public Health. 2018;46(4):436-47. DOI
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and the explanations for the sex differences in informal care rely mainly on redundant arguments indicating that caregiving is not part of men’s social and cultural expectations. The affinity between longevity, women, and widowhood means that family help is provided mainly by daughters. For the same proximity, but for opposite reasons, younger people, especially men, who are more likely to have a partner, see the need for support. Besides the family relationship and sex, cohabitation is also a decisive factor for the caregiver’s option,2121 Hirata H. Care work: a comparison of Brazil, France and Japan. SUR 24. 2016;13(24):53-63. Full text link
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,2222 Giacomin KC, Oliveira Duarte YA, Camarano AA, Pires Nunes D, Fernandes D. Cuidado e limitações funcionais em atividades cotidianas - ELSI-Brasil. Rev Saude Publica. 2018;52(Supl 2):9s. DOI
DOI...
presupposing a common experience whose physical and affective proximity is established in the care and that for widowers is reflected in the children, while for married people, in the spouses. In recent years, the maintenance of informal support has raised several questions and debates that are based, among others, on its sustainability. The changes in recent years in the demographic, social, family, and economic spheres show increasing unavailability for the so-called “family care potential,” which compromises the much desired “aging at home.”2424 Canga A, Vivar C, Durán CN. Dependencia y familia cuidadora: reflexiones para un abordaje familiar. An Sist Sanit Navar. 2011;34(3):463-9. DOI
DOI...
However, the sustainability of institutional resources backed by the welfare state has progressively and increasingly shown its inability to provide support. Finding the balance between institutional and informal support is a major challenge of the coming years of social policies on aging.

The frequency of urinary incontinence proved to be different between men and women, although this was regardless of the sex. The prevalence of urinary incontinence presents very different results in the literature, reflecting the various methodological approaches and association variables under study, albeit being unanimous that it is more prevalent in females and increases exponentially with age and functional dependence. Nonetheless, the linearity and causality between functioning and urinary incontinence remain unclear, and the doubt remains if it is the latter that determines lower functioning levels or if these levels predispose to a disability; nevertheless, their presences coexist and are often contemporary. The structural and physiological causes associated with female urinary incontinence are the weakening of the bladder and sphincter muscles, vaginal and urethral atrophy, difficulty in retaining and emptying the bladder, and increased residual urine volume, in addition to multiparity, hysterectomy, and hormonal alterations due to menopause.2525 Alperin M, Burnett L, Lukacz E, Brubaker L. The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause. 2019;26(1):103-11. DOI
DOI...
Less prevalent than urinary incontinence, and therefore subject to fewer studies, fecal incontinence appears in the literature almost exclusively associated with age and some specific health conditions, such as chronic diarrhea or diabetes.2626 Manuelyan Z, Muñiz KS, Stein E. Common urinary and bowel disorders in the geriatric population. Med Clin North Am. 2020;104(5):827-42. DOI
DOI...

Along with age, sex is one of the demographic characteristics with the most significant weight in differentiating the independence of the elderly, tending globally and positively towards men.11 Boerma T, Hosseinpoor AR, Verdes E, Chatterji S. A global assessment of the gender gap in self-reported health with survey data from 59 countries. BMC Public Health. 2016;16:675. DOI
DOI...

2 Serrano-Alarcón, Perelman J. Ageing under unequal circumstances: a cross-sectional analysis of the gender and socioeco-nomic patterning of functional limitations among the Southern European elderly. Int J Equity Health. 2017;16(1):175. DOI
DOI...
-33 Jacob ME, Marron MM, Boudreau RM, Odden MC, Arnold AM, Newman AB. Age, race, and gender factors in incident disability. J Gerontol A Biol Sci Med Sci. 2018;73(2):194-7. DOI
DOI...
It is not possible to state that the present study results corroborate this conclusion; for the 20 tasks analyzed, differences were only found in 3 (15%). Other authors have already observed this conclusion, especially at older ages.55 Oliveira A, Nossa P, Mota-Pinto A. Assessing functional capacity and factors determining functional decline in the elderly: a cross-sectional study. Acta Med Port. 2019;32(10):654-60. Full text link
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,66 Fontes AP, Botelho MA, Fernandes AA. A funcionalidade dos mais idosos (≥75 anos): conceitos, perfis e oportunidades de um grupo heterogêneo. Rev Bras Geriatr Gerontol. 2013;16(1): 91-107. DOI
DOI...

The worse performance observed in women regarding mobility is usually associated with certain health conditions that are more prevalent in females: arthritic conditions, arthrosis, depression, biological markers resulting from menopause (sarcopenia and osteoporosis), longer life expectancy11 Boerma T, Hosseinpoor AR, Verdes E, Chatterji S. A global assessment of the gender gap in self-reported health with survey data from 59 countries. BMC Public Health. 2016;16:675. DOI
DOI...
,22 Serrano-Alarcón, Perelman J. Ageing under unequal circumstances: a cross-sectional analysis of the gender and socioeco-nomic patterning of functional limitations among the Southern European elderly. Int J Equity Health. 2017;16(1):175. DOI
DOI...
and, according to some authors, socioeconomic vulnerability.33 Jacob ME, Marron MM, Boudreau RM, Odden MC, Arnold AM, Newman AB. Age, race, and gender factors in incident disability. J Gerontol A Biol Sci Med Sci. 2018;73(2):194-7. DOI
DOI...

In the remaining activities/participation analyzed, differences were only found in the activity “washing/drying clothes,” whose results were more unfavorable for men. Usually, men have greater difficulties in domestic life activities, which is more due to cultural and educational reasons than neuromotor disabilities. The “washing/drying clothes” task may be an example of this difference, since it remains socially associated with women, even in younger generations.

The American College of Sports Medicine and the American Heart Association recommend regularly practicing 150 min of moderate-intensity exercise per week for the elderly population in order for health benefits to be observed.2727 American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, Singh MAF, Minson CT, Nigg CR, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510-30. DOI
DOI...
Given these recommendations, the results were positive and contributed to the performance observed in the activities as a protective variable against disability.2828 Sjölund BM, Wimo A, Engström M, von Strauss E. Incidence of ADL disability in older persons, physical activities as a protective factor and the need for informal and formal care - results from the SNAC-N Project. PloS one. 2015;10(9): e0138901. DOI
DOI...
The rurality of the sample may have also contributed to this observation, as it has the underlying habit of people moving primarily on foot due to relational proximities and lack of public transportation.

Despite the promising data found, this study encountered several limitations, including i) the fact that data collection was made through self-reporting, which may have caused some information bias and ii) comorbidities and pain were not considered variables usually related to the functioning profile.

Conclusion

Women are more unprotected in the social and economic dimensions, while men manifest more vulnerable health habits. These differences are linked to demographic issues of longevity and cultural and socialization differences. Differences in activities/participation tend to be blurred between the sexes.

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Edited by

Associate editor:

Angélica Cavalcanti de Sousa

Publication Dates

  • Publication in this collection
    25 Mar 2022
  • Date of issue
    2022

History

  • Received
    16 Nov 2020
  • Reviewed
    03 Dec 2021
  • Accepted
    06 Dec 2021
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