Journal of Clinical Epidemiology 56 (2003) 669–677

Women are more disabled in basic activities of daily living than men
only in very advanced ages: A study on disability, morbidity, and
mortality from the Kungsholmen Project
Eva von Straussa,b,*, Hedda Agüero-Torresa,b, Ingemar Kåreholta,b,
Bengt Winblada,b, Laura Fratiglionia,b
a
Aging Research Center, Division of Geriatric Epidemiology and Medicine, Neurotec, Karolinska Institutet, Stockholm, Sweden
b
Stockholm Gerontology Research Center, Stockholm, Sweden

Abstract
Objective: We explored the effect of morbidity, mortality, and occurrence of new disability on gender differences in activities of daily
living (ADL) functioning in different age groups in the elderly population.
Methods: All 77⫹-year-old members of a community-based cohort were clinically examined by physicians, assessed by psychologists,
and interviewed by nurses at baseline and after a 3-year interval. Diseases were diagnosed according to ICD-9 and the DSM-III-R criteria
for dementia. The Katz index of ADL was used to measure basic functional status.
Results: After adjustment for socio-demographic characteristics, the oldest women (90⫹ years) had higher disability prevalence and
a tendency for higher long-term disability incidence. Women aged 85⫹ years also had higher morbidity prevalence. Mortality among
disabled subjects was similar for both genders, whereas higher mortality was found in younger nondisabled men (77–84 years).
Conclusion: We conclude that gender differences in disability, morbidity, and mortality vary with age in the elderly population. Gender
differences in morbidity and basic functional dependence were evident only in the oldest old. Based on current and previous findings, we
speculate that more women may be at higher risk of developing severe disability than men in the advanced ages due to longer survival
with slight disability earlier in adult life. 쑖 2003 Elsevier Inc. All rights reserved.
Keywords: ADL; Functional status; Gender; Morbidity; Oldest old; Population-based study

1. Introduction higher disability incidence among women [17,18]. Only one

Gender-based differences are a major feature of life ex-
pectancy and mortality trends because women outlive men
in most developed countries by 5 to 9 years [1,2]. However,
in all countries for which data are available, women report
more illness and greater use of health services than men
[3,4]. Women are also at higher risk than men for developing
age-related, nonlethal but disabling, chronic diseases such
as osteoporosis [2] and dementia [5].
Numerous studies on functioning in older adults report
a higher disability among women than men of the same age
[6–14]. There is a disagreement concerning the interpretation
of such gender differences in disability frequency. Some
authors propose a lower mortality among disabled women as
compared with men [11,15,16], whereas others suggest a
* Corresponding author. Stockholm Gerontology Research Center, Box
6401, S-113 82 Stockholm, Sweden. Tel.: ⫹46-8-690-58-47; fax: ⫹46-8-
690-59-54.
E-mail address: eva.von.strauss@neurotec.ki.se (E. von Stauss).
0895-4356/03/$ – see front matter 쑖 2003 Elsevier Inc. All rights reserved.
doi: 10.1016/S0895-4356(03)00089-1
study found a higher disability incidence among men [19].
Oman et al. [20] suggested that the higher prevalence rates of
disability in women compared with men could be explained
by the combined effect of lower recovery and lower mortality
rates in disabled women.
These studies differed largely in the structure of the popu-
lations and disability definitions. Some studies examined
elderly persons as one age-homogenous group (65⫹ or 70⫹)
[7,15,17,18], whereas others used different age strata but
grouped the oldest old into one broad category (75⫹ or
85⫹) [9–11,16,20]. Most studies examined impairment in
activities of daily living (ADL) [7,9,11–15,21], but others
reported dysfunction in mobility [17,19,20] or instrumental
ADL (IADL) [10,18]. It has been difficult to draw any con-
clusion because of these differences.
In a previous study from the Kungsholmen Project [13],
we found that women 90⫹ years old were more disabled in
ADL than men, independently of age, education, and number
of diseases. This could only partly be explained by the excess
670 E. von Strauss et al. / Journal of Clinical Epidemiology 56 (2003) 669–677
of dementia and other chronic diseases among women. We
hypothesized that old women are more disabled than men
because they live longer with their disability than men do.
The present study was designed to verify this hypothesis by
exploring the effects of morbidity, mortality, and occurrence
of new disability on gender differences in ADL functioning
in different age groups.
2. Methods
2.1. Study population
The study population consisted of two groups living in
central Stockholm, Sweden: (1) all the 77⫹ year old subjects
living in the Kungsholmen area and (2) all persons aged 90
years and over registered in the contiguous area, St. Göran,
on 1 January 1992, whether living at home or in institutions.
All subjects were participants in the Kungsholmen Project,
which is a community-based study [22]. The two areas have
homogeneous populations with similar age and gender distri-
bution, and on average the subjects had lived 49.6 years in
the Kungsholmen area and 45.1 years in the St. Göran area.
All participants were clinically examined by physicians
and cognitively assessed by psychologists. The elderly sub-
jects and their next-of-kin were interviewed by trained nurses
using a structured questionnaire that covered living condi-
tions, social status, cognitive function, and functional dis-
ability. A detailed description of the methods has been
reported elsewhere [23]. Both populations were followed
for a minimum of 3 years or until death. The follow-up
evaluation of the population was carried out on average
39 ⫾ 6.8 months after the first examination. The minimum
time from first examination to follow-up was 20.5 months,
and the maximum time was 60.5 months. Fifty-five percent
of the subjects were examined within 39 months, and 80%
were examined within 44 months.
The research follows the guidelines of the Swedish Coun-
cil for Research in the Humanities and Social Sciences [24],
and the study was approved by the Ethics Committee of the
Karolinska Institutet.
2.2. Functional status
Functional status was measured by the Katz index of ADL
[25], which is a hierarchical scale formed by dependency in
the following six activities: bathing, dressing, going to the
toilet, transferring, continence, and feeding. Level of depen-
dence was expressed in grades: A represented the most
independent (requiring no personal assistance in all six
activities), and G represented the most dependent grade
(requiring assistance in all six activities). In this article, func-
tional independence is defined as no need for assistance or the
need for assistance in one activity (Katz index ⫽ A ⫹ B),
partial disability was defined as need of assistance in two
to four specified activities (Katz index ⫽ C ⫺ E), and total
disability was defined as need of assistance in five or six
specified activities (Katz index ⫽ F ⫺ G). Categorization
followed Katz’ recommendation [25]. Data on functional
status were collected by a nurse by questioning and observ-
ing the subjects. Good reliability and construct validity of
this scale, when administered by nurses, have been pre-
viously reported [26].
Development of functional dependence was defined as a
change in functional status from being functionally indepen-
dent (no need for assistance or need of assistance in one
activity) to functionally dependent (need of assistance in
two or more activities) during follow-up.
2.3. Morbidity
Physical and mental health was assessed at baseline and
follow-up by the physician during the clinical examination
and, if necessary, with the support of next-of-kin interview.
Mental health included assessment of major depression and
dementia. Diagnoses of major depression were made by a
psychiatrist according to DSM-IV criteria [27,28] by using
data from the Comprehensive Psychopathological Rating
Scale [29]. The DSM III-R diagnostic criteria [30] were
used for the clinical diagnosis of dementia [23,31]. Other
diagnoses were made according to the International Classi-
fication of Diseases - Ninth Revision (ICD-9) [32]. In this
study, only current chronic diseases were included.
Morbidity was summarized in a three-item index: having
no chronic disease, having one chronic disease, or having two
or more chronic diseases. Stroke and hip fracture were in-
cluded in this definition when they resulted in chronic se-
quels. Other diseases were hematologic diseases, cardio- and
cerebrovascular diseases, endocrine diseases, gastrointesti-
nal diseases, infectious diseases (such as tuberculosis and
polio), malignancy, neurologic diseases, osteoporosis and ar-
thritis, psychiatric diseases, and respiratory diseases.
2.4. Social characteristics and mortality data
Socio-demographic characteristics such as age, gender,
marital status, and living situation were derived from local
authorities’ offices. Education was assessed at baseline di-
rectly from the subjects or from an informant in case of
cognitive impairment as the highest educational level
achieved. Mortality data for all participants were derived
monthly from the Swedish National Death Register.
2.5. Data analysis
Age- and gender-specific prevalence estimates for mor-
bidity and disability were calculated. To verify the impact
of disability on mortality and possible gender differences,
Kaplan-Meier survival curves were created for functionally
dependent and independent subjects after stratification by age
and gender. Log rank tests were used to evaluate the equality
of survival distributions for disability. Survival time, specific
for functional status stratified by age (77–84 years and 85⫹
 E. von Strauss et al. / Journal of Clinical Epidemiology 56 (2003) 669–677 671

years) and gender, were calculated as the time between base-
line and death.
To detect possible gender differences in disability, mor-
bidity, and mortality, we constructed different logistic regres-
sion models with the following dependent variables: (1)
disability at baseline: no assistance or assistance in one
activity versus need of assistance in two or more activities;
(2) development of disability during 3-year follow-up: pro-
gression from no assistance or assistance in one activity
to need of assistance in two or more activities; (3) morbidity at
baseline: having no chronic disease versus having at least one
disease; and (4) death during the 3-year follow-up. All analy-
ses included age and education as covariates.
3. Results
Of the 1848 subjects in the study population, 9.1% died,
3% had moved from the areas before examination, and
12.3% refused to participate. Thus, 1424 persons were clini-
cally examined at baseline, and 502 of them were 90 years
or older.
Socio-demographic characteristic and morbidity at base-
line are presented in Table 1. The majority of the subjects
were women, especially in the 90⫹ group (83.1%). Forty-
five percent of the men and 37% of the women had more
than 7 years of schooling (P ⬍ .01). Women aged 77 to 84
years had significantly higher education than women in the
older age groups (P ⬍ .01). Nineteen percent of the subjects
were still married, with a significantly higher percentage of
men compared with women (P ⬍ .001). In the 90⫹ group,
35% of the men were still married, but only 4% of the
women were. Most people lived at home, and 75% of them
lived alone. More women than men lived alone at home
(P ⬍ .001).
At baseline, 85⫹-year-old women had a significantly
higher prevalence of morbidity than men (Table 1). Women
had more fractures and osteoarticular diseases than men in all
age groups (P ⬍ .001), whereas in the highest age group
(90⫹ years), women had more dementia disorders (P ⬍ .01).
Men had a higher prevalence of malignancy (P ⬍ .01).
Women aged 90⫹ years were the most disabled group
(P ⬍ .01) and needed almost twice as much assistance as
men in all items (Table 2). Women in this age group were
also more disabled partially (needing assistance in two to
four activities) and totally (needing assistance in five to six
activities) than men, whereas women aged 85 to 89 years
only were more partially disabled than men. No gender
difference in disability was present among subjects aged 77
to 89 years.
During the follow-up, 518 subjects died. A logistic regres-
sion model showed that the deceased subjects compared with
survivors were older (odds ratio [OR] 1.1, 95% confidence
interval [CI] 1.0–1.1), less educated (OR 1.4, 95% CI 1.1–
1.8), less frequently women (OR 0.7, 95% CI 0.5–0.9), and
more demented (OR 2.1, 95% CI 1.6–2.9) and disabled (OR
2.8, 95% CI 1.9–4.1) at baseline. The mean survival time
within 3 years from the initial examination was 1.9 years
(95% CI 1.7–2.0) and 2.6 years (95% CI 2.6–2.7) respec-
tively, for functionally dependent and independent subjects.
Kaplan-Meier curves were used to compare survival between
functionally dependent and independent men and women
in two age groups (77–84 years and 85⫹ years) (Fig. 1).
Functionally dependent subjects had significantly shorter
survival than independent subjects in both age groups (log

Table 1
Sociodemographic characteristicsa and morbidity of the study population at baseline (percent distribution by age and gender)
Age groups (yr)
Women Men
77–84 (n ⫽ 438) 85–89 (n ⫽ 258) 90⫹ (n ⫽ 417) 77–84 (n ⫽ 155) 85–89 (n ⫽ 71) 90⫹ (n ⫽ 85)
Education
Low (⬍8 yr) 57.9 65.4 67.6 51.0 57.7 60.7
High (8⫹ yr) 42.1 34.6 32.4 49.0 42.3 39.3
Marital status
Singleb 84.2 91.4 95.9 40.3 51.4 65.5
Living situation
At home 89.7 77.9 51.6 91.0 81.7 77.7
Service buildingc 5.0 10.5 18.9 3.2 4.2 8.2
Institution 5.3 11.6 29.5 5.8 14.1 14.1
Morbidity
No chronic disease 22.8 19.0 17.3 27.8 31.0 25.9
1 chronic disease 45.2 44.6 51.3 44.5 40.8 45.9
2⫹ chronic diseases 32.0 36.4 31.4 27.7 28.2 28.2
a
Missing data on education for one man and eight women, or marital status for three men and five women.
b
Unmarried, divorced, or widowed.
c
A service binding is a block of flats containing 20–100 apartments, each consisting of 1–3 rooms plus kitchen and bathroom. Usually there are also
a restaurant, a day center, and activity rooms in the building.
672 E. von Strauss et al. / Journal of Clinical Epidemiology 56 (2003) 669–677

Table 2
Baseline disability in single ADL according to the Katz ADL index (percent distribution by age and gender)
Age groups (yr)
Women Men
77–84 (n ⫽ 438) 85–89 (n ⫽ 258) 90⫹ (n ⫽ 417) 77–84 (n ⫽ 155) 85–89 (n ⫽ 71) 90⫹ (n ⫽ 85)
a
Disability in ADL
Bathing 9.2 19.3 36.4 9.2 11.4 20.2
Dressing 6.2 11.0 25.3 6.5 8.7 15.5
Going to toilet 5.1 9.8 24.8 5.2 11.4 13.1
Transfer 6.0 8.3 21.8 4.6 10.0 11.9
Continence 3.7 6.0 17.7 4.6 8.6 7.2
Feeding 3.7 8.3 22.1 3.9 5.7 11.9
Functional status
Independentb 92.6 88.2 69.8 93.5 90.0 85.7
Partially dependentc 3.7 5.5 14.5 3.9 2.9 6.0
Dependentd 3.7 6.3 15.7 2.6 7.1 8.3
Abbreviation: ADL, activities of daily living.
a
Missing data for four men and sixteen women.
b
Needing no assistance or assistance in one activity (Katz index ⫽ A ⫹ B).
c
Needing assistance in two to four specific activities (Katz index ⫽ C⫺E).
d
Needing assistance in five to six specific activities (Katz index ⫽ F⫺G).

rank test: P ⬍ .001). Among functionally dependent elderly elderly persons, men aged 77 to 84 years had a signifi-
persons, there was no gender difference in survival in cantly shorter survival time than coeval independent
either age group, whereas for functionally independent women.

Fig. 1. Survival curves for functionally independent (needing no assistance or assistance in one activity; Katz index ⫽ A ⫹ B) and dependent (needing
assistance in two or more specific activities; Katz index ⫽ C ⫺ G) subjects stratified by gender in the two age groups 77–84 years and 85⫹ years.
 E. von Strauss et al. / Journal of Clinical Epidemiology 56 (2003) 669–677
Fig. 1. Continued.
After an average follow-up time of 3 years, 65% (773)
of the initially nondisabled subjects (n ⫽ 1190) were re-
examined; 351 had died, and 66 refused the follow-up exami-
nation. At follow-up there were no disability data for six
persons. Of the initially nondisabled subjects who survived
until follow-up examination, 15.2% had become dependent
(15.9% of the women and 13.1% of the men).
Logistic regression models, with age and education as
covariates, were carried out to verify the gender differences in
disability and morbidity at baseline and in development of
new disability and death during the 3-year follow-up (Table
3). A statistically significant association between female
gender and presence of at least one chronic disease was
detected in the 85 to 89 age group. Women aged 90⫹
years were also more disabled, even after adjustment for
morbidity (OR 2.2, 95% CI 1.1–4.3). In addition, we
performed ordinal logistic regression analysis with disability
as a trichotomized outcome and binary logistic regression
analysis modeling the interaction between age groups and
sex. An interaction term—that is, significant on the 10%
level (P ⫽ .091)—confirms that older women are more dis-
673
abled than older men (OR 1.1; 95% CI 1.0–1.2). The differ-
ence between the three age groups is not the same, indicating
that the increase of disability in women does not increase
exponentially with age but more between the 85 to 89 and
90⫹ age groups than between the 77 to 84 and the 85 to
89 age groups. In the two younger age groups, men had an
increased risk of death, but mortality among disabled sub-
jects was similar for both genders in all age groups. The excess
of mortality among younger men was due to the increased
risk of death in the functionally independent men (OR 0.4,
95% CI 0.3–0.7). The risk of developing disability during
follow-up was increased among 85⫹-year-old women, but
the difference from that for similarly aged men was not sig-
nificant when adjusted for age, education, and morbidity.
4. Discussion
We investigated health and functional status in a large
population-based cohort of 77⫹-year-old adults and found
that there are gender differences in disability, morbidity,
674 E. von Strauss et al. / Journal of Clinical Epidemiology 56 (2003) 669–677
Table 3
Gender differences in health status for different age groupsa
Adjusted OR (95% CI) of women compared with men
77–84 yr
Being disabledb 1.1 (0.5–2.3)
Having at least one chronic disease 1.3 (0.8–1.9)
Being disabled independently of the 1.0 (0.5–2.1)
presence of chronic diseases
Development of new disability in 3 yr 0.7 (0.3–1.8)
Development of disability in 3 yr 0.7 (0.3–1.7)
independently of morbidity at baseline
Death in 3 yr
For the whole population 0.5 (0.3–0.7)
For the subpopulation of functional 0.9 (0.2–4.2)
dependent subjects
For the subpopulation of functional 0.4 (0.3–0.7)
independent subjects
Abbreviations: OR, odds ratio; CI, confidence interval.
a
Adjusted OR and 95% CI derived from eight separate logistic regression models. OR adjusted for age (continuous) and education (elementary/vocational
versus high school/university).
b
Needing no assistance or assistance in one activity versus needing assistance in two or more activities.
and mortality. These differences vary with age: (1) A higher
disability prevalence in women than in men was observed
only in the very old subjects (90⫹ years). There was also
a tendency for higher incidence of long-term disability in
women compared with men in the age group 90⫹ years.
(2) Women aged 85⫹ years had a higher morbidity preva-
lence than men. (3) Mortality among functionally indepen-
dent subjects was higher for men in the youngest age group
(77–84 years), whereas mortality among disabled subjects
was similar for both genders in all age groups.
4.1. Gender differences in basic ADL disability
is present only in the very old (90⫹ years)
We assessed physical functioning in ADL, including the
impairment of two or more basic functions, following Katz
recommendations of how to measure disability [25]. We
assessed a fairly severe dysfunction in comparison with
other studies that have assessed functioning in mobility and
IADL. Most studies have used the Katz index of ADL [25]
and found a higher disability prevalence among older wo-
men than men of the same age (Table 4). However, four
of these studies examined the elderly subjects as one age-
homogeneous group (65⫹ or 70⫹ years old) [7,15,17,18],
and eight studies used different age strata but grouped the
oldest old into one broad category (75⫹ or 85⫹ years) [9–
11,20,21,33–35]. This large age range grouping was due to
the small sample size in the highest ages and could have
masked differences in the different age groups. In our study,
a large number of nonagenarians enabled us to study the effect
of gender on disability in different age strata. The higher
disability prevalence only among the 90⫹-year-old women
that we found is consistent with reports from Lyons et al. [36].
These authors examined a large population aged 70 to 99
years in three districts in the United Kingdom, using the Bar-
thel index of ADL [37] measuring basic ADL activities and
85–89 yr 90⫹ yr
1.2 (0.5–2.8) 2.3 (1.2–4.5)
1.9 (1.0–3.5) 1.6 (0.9–2.8)
1.0 (0.4–2.5) 2.2 (1.1–4.3)
1.3 (0.5–3.6) 1.7 (0.7–3.8)
1.3 (0.5–3.4) 1.6 (0.7–3.8)
0.8 (0.5–1.4) 1.3 (0.8–2.1)
1.7 (0.2–12.0) 0.9 (0.2–3.5)
0.7 (0.4–1.2) 1.1 (0.7–1.9)
mobility. They found that women were more disabled than men
in all age groups but radically so in the age group 90⫹ years.
In conclusion, our findings suggest that women are more
disabled than men only in very advanced ages when depen-
dence in basic ADL is examined. Our results show that the
age-related increase in disability is larger for women than
for men, although the difference is significant only at the
10% level. Data from the literature support this hypothesis
by showing gender differences in ADL disability after 85
years [13,18,33,36,38] and in IADL disability in the younger
old age [18,20].
4.2. Women aged 90⫹ years had higher disability
incidence than men
We found a higher incidence rate of disability in 90⫹-
year-old women compared with coeval men; however, the
few men in the very high ages limited the power of our
study for detecting a statistically significant difference. Two
studies have also reported higher incidence rates of disability
among older women in the ages 72⫹ years [17] and 85⫹
years [18]. However, other studies in Canada [35], the United
States [8,20,39–41], and Sweden [42] did not confirm this
finding. In our study, the incidence of long-term disability
(disability that develops over a 3-year period) was measured;
the subjects who died during this period and had devel-
oped disability before death were not included in the
study population.
4.3. Women aged 85⫹ years old had higher morbidity
prevalence than men
The gender differences in disability found in our study
were not eliminated when the presence of chronic diseases
was taken into account. Almost 22% of the subjects in our
population had no chronic disabling diseases. Older women
 E. von Strauss et al. / Journal of Clinical Epidemiology 56 (2003) 669–677 675

Table 4
Some population-based studies on ADL in the elderly: age structure of study population. disability measures used, and mian results (relation of
disability with age and gender)
Disability
Sample size
Relation with
(participants Ages studied
Place and reference at baseline) (yr) Measures Agea Genderb
Europe
Odense, Denmark [14] 2262 92–93 Katz ADL w⬎m
Veneto Region, Italy [34] 2373 65–74, 75–84, 85⫹ Katz ADL, IADL, mobility ↑ w⬎m
Stockholm, Sweden [13] 502 90–94, 95⫹ Katz ADL ↑ w⬎m
SWEOLD, Sweden [21] 508 77–79, 80–84, 85⫹ Katz ADL, mobility, performance ↑ w⬎m
England & Wales, UK [36] 1608 70–79, 80–89, 90–99 Barthel index ↑ w⬎m
North America
The Alameda County Study, USA [15] 508 65⫹ Katz ADL, IADL →c w ⬎ mc
Marin County, California, USA [20] 1982 55–64, 65–74, 75–84, 85⫹ Lower-body disability ↑ w⬎m
↑c w ⫽ mc
New Haven, Connecticut, USA [17] 664 72⫹ Katz ADL, performance ↑c w ⬎ mc
Duke, Durham, North Carolina, USA [7] 297d 65⫹ OARS ↑c w ⬎ mc
Framingham, Massachusetts, USA [9] 1453 63–74, 75⫹ Katz ADL, Barthel index ↑ w⬎m
National Long Term Care Surveys, 5000 65⫹, 85⫹ Katz ADL, IADL ↑ w⬎m
USA [11]
Longitudinal Study of Ageing, USA [18] 5092 70⫹ Katz ADL ↑c w ⬎ mc
Sherbrooke, Québec, Canada [35] 572 75–79, 80⫹ SMAF ↑c w ⫽ mc
Asia and the Pacific
Shanghai, China [33] 3745 65–69, 70–74, 75–79, 80–84, 85⫹ CADL (from OARS) ↑ w⫽m
Mosgiel, New Zealand [10] 782 70–74, 75–79, 80–84, 85⫹ Katz ADL, IADL ↑ w⬎m
Abbreviations: ADL, activities of daily living; CADL, the Chinese version of activities of daily living; IADL, instrumental activities of daily living;
OARS, Older Americans Resources and Services; SMAF, Functional Autonomy Measurement System.
a
Disability increases with age (↑); no change in disability with age (→).
b
Women are more disabled than men (w ⬎ m); no gender difference in disability (w ⫽ m).
c
Incidence studies.
d
Subjects at follow-up.

(85⫹ years) had more diseases than men due mainly to the
higher prevalence of fractures and osteoarticular disorders
and dementia, which is in agreement with previous re-
ports [3,4,12,43]. Several studies have shown that dementia
and musculoskeletal disorders are strongly associated with
severe functional limitation [18,33,34,44,45]. However,
these diseases did not explain the gender difference in
our study. A possible explanation is that we did not take
into account nonchronic diseases that occurred earlier in
life. In addition, we did not examine disease severity. Fur-
thermore, we did not take into account other factors that
may also influence functioning, such as lower socio-
economic status [7,15], nutrition [46], and lifestyle habits
[15,47]. We have controlled only for the effect of education
[7,19,21,48], which is regarded as a good indicator of socio-
economic status for the elderly population [49,50] and as a
broad indicator of nutrition and life styles [51,52]. Because
data on height and weight were not available for all
subjects, the relation between body mass index and func-
tional limitations was not explored.
4.4. Differential mortality between genders is present
only in the youngest functionally independent people,
with men at higher risk of death
In agreement with the well established knowledge con-
cerning a lower mortality risk among old women than
men [3,16,35,48], we found that functionally independent
men had a higher risk of death than functionally indepen-
dent women [18], but this difference was evident only in the
younger age group (77–84 years).
Our findings did not support the hypothesis that women
live longer in a disabled status than men [11,15,20] because
disabled women and men had similar risk of death, although
higher than nondisabled subjects. Our findings concern
severe physical dependence because we studied disability
in basic ADL functions (such as bathing, dressing, transfer-
ring from bed to chair, eating, etc.). It is likely that the
deceased men in the younger age group could have had
some light disability that we were unable to detect with our
functioning scale (Katz ADL scale) [25]. This hypothesis is
supported by a study of Oman et al. [20], who examined
mobility disability in 75- to 84-year-old subjects and
found that women had a higher prevalence of light disability
due to lower recovery and lower mortality. Taken together,
these results may suggest that women with light disability
outlive men from 77 to 84 years to the oldest ages, and for
that reason they are at higher risk of developing severe
disability in the very old ages.
5. Conclusions
We found that morbidity, disability, and mortality patterns
were different in different age groups in the elderly popula-
tion, indicating that there is an heterogeneity in ageing
676 E. von Strauss et al. / Journal of Clinical Epidemiology 56 (2003) 669–677
[42,53]. Gender differences in morbidity and basic functional
dependence were evident only in the oldest old (90⫹ years).
Based on current and previous findings, we speculate that
more women may be at higher risk of developing severe
disability than men in the advanced ages due to the longer
survival of women with slight disability earlier in adult life.
Our findings underline the need to differentiate people in
the older ages into groups and to examine basic functioning
and mobility and instrumental function separately because
they reflect different severity levels of functional depen-
dence. Finally, if confirmed, our results are relevant for
prevention. The youngest old women with slight impairment
may be a suitable target group for interventions before the
development of severe disability. Because women represent
the largest proportion of the elderly, preventive interventions
have the potential for significant public health impact.
Acknowledgments
This study was supported by grants from the Swedish
Council for Social Research, the Swedish Medical Re-
search Council, the Swedish Municipal Pension Institute,
Torsten & Ragnar Söderbergs Foundation, Gun and Bertil
Stohne Foundation, Loo and Hans Ostermans Foundation,
the Swedish Society for Medical Research, the Alzhei-
merfoundation Sweden, and SHMF-90 Foundation. We
thank all the members of the Kungsholmen Project Study
Group for data collection and management and Katie Palmer
and Vince Thomas for providing valuable comments.
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