Unique health needs of elderly women being ignored, symposium told

Elderly women, who form Canada's fastest-growing population segment, are also its most ignored segment when it comes to health care research, physicians attending the recent annual meeting of the Royal College of Physicians and Surgeons of Canada were told. FIGURE

Figure. Is the fastest-growing segment of the population also the most ignored?

A 65-year-old woman has a 50% chance of reaching age 85, yet there is little research on her unique health needs. "Ninety-nine point nine percent of research is on women under 80," said Dr. George Kuchel, director of the Division of Geriatric Medicine at the McGill University Health Centre. He made the comments during a symposium, Health Care for Elderly Women: Clinical Issues and Future Perspectives.

Kuchel pointed to a dearth of research on the long-term impact of menopause, noting that "a 90-year-old woman has been postmenopausal for 40 years." Not only must clinical research include women older than 80, he said, but it also needs to identify cellular markers for disability and frailty in the elderly.

Elderly women do have unique characteristics. For example, several studies now show that bone loss continues after age 80. As well, said Dr. Cara Tannenbaum, the symposium moderator, "we're not doing a good job [delivering] primary or secondary [care]."

The needs of these women are bound to increase as the population ages. Between 1960 and 1990 the number of Americans aged 85 years of age or older increased by 232%; the total population grew by 39%. The ratio is likely similar in Canada. And among these "oldest old," women outnumber men by a ratio of 2.6:1.

Dr. Anne Newman, an associate professor (geriatrics) at the University of Pittsburgh School of Medicine, pointed out that even though women live longer than men, they usually are more disabled. "Doctors need to remember that women who are 70 years old will likely live on average another 15 years," said Newman. Sixty percent of patients over age 65 are women, as are 70% over age 85. However, women spend twice as much of their life disabled - 3 years, compared with 1.5 years for men - and people with disabilities face 2 to 3 times the risk of hospitalization. Newman said women are more likely to report multiple chronic conditions. For example, 53% report arthritis (compared with 40% of men) and one-third of disabilities are related to arthritis.

Women are also 50% more likely to fall, which is a major factor in nursing home admissions. As well, their longevity means that they are more likely to develop Alzheimer's disease and dementia. Although men of all ages are at greater risk of cardiovascular disease (CVD), the gap narrows with age. CVD is the most disabling comorbidity for both sexes. "Health care professionals must pay attention to these conditions, especially arthritis and CVD, [if they are] to minimize disability," said Newman.

Osteoporosis beyond age 80

Osteoporosis is also a significant comorbidity factor that can rapidly become a primary disabler, since fractures are 4 times more common than stroke in the over-80 age group. Older women with repeat fractures are often told that nothing can be done for them, but Dr. Suzanne Morin, a member of McGill University Health Centre's Osteoporosis Clinic, disagrees. She advocates therapy to prevent fractures, and precautions to reduce the risk of falls. For women over age 80, Morin suggests that they take vitamin D and calcium supplements, that they exercise to improve balance and take steps to prevent falls. She said women with low bone density or who have had previous fractures should consider therapeutic agents such as low-dose hormone replacement therapy, but emphasized the need for more trials.

Vitamin D and calcium have been shown to reduce the risk of hip fractures by about one-third among institutionalized elderly people, but Dr. Richard Crilly and colleagues at the University of Western Ontario found that fewer than 3.5% of some 28 000 long-term-care patients across Canada were receiving vitamin D and calcium.

Cardiovascular disease

Older people generally receive less therapy for CVD, but this is especially true of older women. Dr. Terry Montague, director, patient health for Merck Frosst Canada Inc., told the symposium that older women are less likely to receive prophylactic measures such as special diet instructions and information on smoking cessation or exercise programs. "There is a debate over whether it's worth while to treat older people," said Montague. He also pointed out that although men are more at risk of developing CVD, the risk begins to even out after age 65 and is almost even between men and women by age 75.

Dementia

Dr. Howard Chertkow, associate professor of medicine (neurology) at McGill and codirector of the Memory Clinic at the Jewish General Hospital, said he is surprised that no one is studying the differences in results in diagnostic studies involving men and women. Early diagnosis remains the key to early management, said Chertkow; pointing to recent guidelines, he said more FPs and internists need to learn effective diagnosis.1 "Diagnosis is difficult and time consuming for the family physician but the responsibility goes back to them," he said. "We have to encourage them to develop expertise."

In Canada, primary risk factors include family history, low education levels and exposure to glues and pesticides. Pharmaceutical therapies can offer stabilization and modest improvements, and postmenopausal women who use estrogen may be at less risk of dementia, but there is a need to confirm these findings in prospective, randomized multicentre trials.

Incontinence

About 20% of women aged 70 or more who live in the community are incontinent, as are half of those in acute care. The cost of incontinence in the US amounted to $8 billion in 1990 and it accounted for a quarter of the total costs in nursing homes. By 1995 this figure had soared to $30 billion. But Kuchel, who also serves as director of the Geriatric Incontinence Clinic at the McGill University Health Centre, said this doesn't even take into account the huge effect on quality of life.

Aging contributes to the problem but is not the cause, and bladder dysfunction is not a full explanation. Kuchel said the risk factors include age, poor mobility, neurological diseases and dementia.