Sex differences in the management of persons with dementia following a subnational primary care policy intervention

Abstract

Background The influence of sex and gender on the risk of dementia, its clinical presentation and progression is increasingly being recognized. However, current dementia strategies have not explicitly considered sex and gender differences in the management of dementia to ensure equitable care. The objective of this study was to examine the moderating effect of sex on the quality of care following the implementation of the Quebec Alzheimer Plan (QAP). Methods We conducted a secondary analysis of the evaluation of the QAP consisting of a retrospective chart review of 945 independent, randomly-selected patient charts of males and females 75+ years old with dementia and a visit to one of 13 participating Family Medicine Groups before (October 2011–July 2013) and after (October 2014 – July 2015). The quality of dementia care score, based on Canadian and international recommendations and consensus guidelines, consisted of documented assessments in 10 domains. We used a mixed linear regression model to measure the interaction between sex and the implementation of the QAP on the quality of dementia care score, adjusting for age and number of medications. Results We found that improvements in the quality of dementia care following the QAP were larger for men than women (mean difference = 4.97; 95%CI: 0.08, 9.85). We found that men had a larger improvement in four indicators (driving assessments, dementia medication management, Alzheimer Society referrals, and functional status evaluation), while women had a smaller improvement in three (home care needs, behavioural and psychological symptoms of dementia, and weight). Men were prescribed fewer anticholinergics post-QAP, while women were prescribed more. Cognitive testing improved in men but decreased for women following the QAP; the opposite was observed for caregiver needs. Conclusion While the overall quality of care improved after the implementation of the QAP, this study reveals differences in dementia management between men and women. While we identified areas of inequalities in the care received, it is unclear whether this represents inequities in access to care and health outcomes. Future research should focus on better understanding sex and gender-specific needs in dementia to bridge this gap and better inform dementia strategies.

Impact of the COVID-19 Pandemic on Home Care Services Among Community-Dwelling Adults With Dementia

“…12 Sex, rurality, and income quintile were chosen as strata as they have been previously tied to inequalities in access to care that could be exacerbated by the pandemic. 13,14…”

National Dementia Strategies in OECD Countries: A Focus on Inequities

“…for example, lower SES has been associated with higher incidence of dementia, local deprivation has been associated with higher risks of cognitive impairment and cognitive decline (6,9), and sex differences have been associated with specific risk factors of dementia (10). The discrepancy in the risk of developing dementia in men and women likely stems from the trends that show women live longer on average compared to men, and are also less likely to be as educated or engage in as much exerciseall of which are risk factors for dementia (10). Unfortunately, the risk factors for health inequities are not always taken into account when implementing large-scale health reform, and because of this, many persons with dementia are left experiencing significant physical, mental, and emotional hardship.…”

“…At its core, dementia affects the neurocognitive system, resulting in impaired cognitive ability that in many cases, impacts a person's ability to engage in activities of daily living (25). Dementia has also been associated with significant comorbidities and disabilities, causing many persons living with dementia to experience accelerated cognitive decline, have more difficulty managing chronic conditions, and face challenges accessing routine care, in addition to the challenges that accompany a dementia diagnosis (10,26,27). On average, people living with dementia who are over the age of 65 have an average of four comorbidities, and over 90% of persons living with dementia have at least one other health condition (28).…”

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“…Since early intervention in diabetes improves long-term outcome, this may also have implications for the incidence of (cerebral) complications (Group UPDS, 1998). The same truth holds for cognitive impairment: women with dementia are generally referred later than men (Howard et al, 1998;Sourial et al, 2020). Women might therefore experience delay in receiving adequate supporting care when experiencing cognitive impairment.…”