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Sexual Health in the Older Patient Lindsay Wilson, MD MPH Assistant Clinical Professor Division of Geriatric Medicine Department of Internal Medicine Reflections What have you observed: --Do older people get asked about sexual issues? --Have you observed older adults receive education from physicians on prevention of STIs? sexual dysfunction? What have you heard from grandparents, parents, older people you know (that they would be comfortable with you sharing, of course!)? With regards to sex, what are our responsibilities to our older patients? Objectives: The objectives of this lecture are to --Outline the prevalence of sexual behavior and dysfunction in older adults --Discuss treatments for sexual dysfunction --Introduce specific concerns related to sexual health in older adults --Emphasize how the care of sexual health in older people illustrates important approaches to geriatric patient care Part 1. Prevalence of Sexual Behavior and Sexual Dysfunction Prevalence of Sexual Behavior From a survey --About 3/4 of those 57-64 --1/2 of those 65-74 --1/4 of those 75-85* --Women < Men at all ages *From Lindau Stacy Tessler, Philip Schumm, Edward Laumann et al. A study of sexuality and health among older adults in the United States. NEJM 2007; 356:762-774. **http://voices.yahoo.com/betty-white-quotes-golden-girls-still-sex7774328.html?cat=7 Sexual behavior --Declines with age but lower prevalence is especially associated with poorer health ratings* *From Lindau Stacy Tessler, Philip Schumm, Edward Laumann et al. A study of sexuality and health among older adults in the United States. NEJM 2007; 356:762-774. Sexual behavior Another key factor is having an able/willing partner: **Betty White, when asked if 88 year-olds still have sex: "If one gets lucky I bet they do." *From Lindau Stacy Tessler, Philip Schumm, Edward Laumann et al. A study of sexuality and health among older adults in the United States. NEJM 2007; 356:762-774. **http://voices.yahoo.com/betty-white-quotes-golden-girls-still-sex7774328.html?cat=7 Sexual Issues Among respondents who were sexually active, about half of both men and women reported at least one bothersome sexual problem.* *From Lindau Stacy Tessler, Philip Schumm, Edward Laumann et al. A study of sexuality and health among older adults in the United States. NEJM 2007; 356:762-774. Sexual issues Men: -erectile difficulties (37%): 14% of all men reported using medication or supplements to improve sexual function.* --ED affects as many as 50% of men over 40** *From Lindau Stacy Tessler, Philip Schumm, Edward Laumann et al. A study of sexuality and health among older adults in the United States. NEJM 2007; 356:762-774. **From Carson C. Sildenafil: A 4-Year Update in the Treatment of 20 Million Erectile Dysfunction Patients. Current Urology Reports 2003. Factors that contribute to erectile dysfunction: 1. Vascular: smoking, HLD, HTN, DM 2. Neurogenic: DM, prostate surgery, bicycling 3. Medication-Induced: BP meds, SSRIs, anticholinergics Sexual Issues Women low desire (43%) difficulty with vaginal lubrication (39%) inability to climax (34%) Part 2. Treatment of Sexual Dysfunction Treatment of ED 1. Oral PDE type 5 inhibitors Sildenafil (Viagra) • 49% of the market--most common for geriatric • • • • patient Expensive if no insurance; Pfizer Web Site: discount Counterfeit market/on-line purchasing Patient will need counseling on instructions and side effects Do not prescribe if patient is on nitrates Viagra continued... --Can’t predict failure based on any characteristic including age (so hope for the best) --Failure can result from poor follow-up and/or instruction on use and dosing --Improvement is about 50-90% vs 11-41% for placebo Other Treatments of ED 1. 2. 3. 4. Vacuum device Suppositories Injections Surgical options What about testosterone therapy? Testosterone therapy in the older male •Testosterone levels naturally decline with age •Unlikely to help unless... •Testosterone therapy has various risks and requires monitoring for adverse effects My recs for prescribing testosterone to an older male 1) Ask, Does he have clinical syndrome? 2) Target metabolic syndrome first. 3) Discuss uncertainty of benefits/risks with patient. 4) Have a lower target testosterone level such as 300. 5) Monitor for evidence of testosterone-dependent disease. 6) Go ahead and screen for secondary osteoporosis. Low desire in women (and men) is multifactorial --Review medication list --May be due in part to prior sexual experiences (discomfort during sex can lead to conditioning) --Consider mood disorder, stress, hypothyroidism, cardiovascular disease, diabetes, incontinence, body image Low desire continued... --Desire theories: "Use it or lose it" and "try it and get it" (Basson’s circular sexual response cycle) --Exercise (moderate) may help --Testosterone replacement? --This is not always a problem--if it does not cause the patient distress, don't make it a health “concern” Vaginal dryness can lead to dyspareunia (pain with sex) Moisturizers Lubricants Estrogen creams Vitamin E gel caps (can stain) No to petroleum jelly Lubricant or moisturizer? Lubricant or Moisturizer? Inability to orgasm --Often multifactorial and complex --Review medication list --Treat vaginal dryness --Sexual satisfaction can still occur Part 3. Intro to Specific Issues Related to Geriatric Patients and Sexual Health--Many Deserve an Entire Lecture Brief intro into some specific issues.... Fitness for sexual intercourse Exertion is dependent on position, partner, situation (low risk in a monogamous relationship, familiar setting, no excess ETOH) Approximated at 4-5 mets (like going up a flight of stairs) Princeton Guidelines (based on expert opinion, not RCTs): If unstable heart disease, no sexual activity. If 3 or more risk factors, consider more evaluation. Kostis JB, Am J Cardiol 2005; 96: 313-321. Sexuality and Dementia *May see increased or decreased interest in sex *If increased interest reaches concerning levels, can try SSRI (off-label use, decreases libido) *Usually there are changes in levels of inhibition *Sometimes what seems sexual, may not be--is there a urinary, GI symptom that is provoking the behavior *Alzheimer's Society "Sex and Dementia" website is a great resource. *Pregnancy and sex were often a very memorable time. Sexually-transmitted infections Older patients may be less likely to use condoms Older patients are less likely to be screened for HIV and receive early intervention Counsel on safe sex practices as you would with younger patients Additional resource: UNC site Elder HIV Residential Homes Respect privacy Keep an open-mind while promoting health and safety LGBT patients *This deserve an entire lecture to itself--there is a great module on line--google lgbt health education module 6 Caring for Older LGBT Adults from the Fenway Institute 2009 *Historic discrimination affects the health care of older LGBT *Be open and aware, support and advocate for your patient *LGBT adults (as should all adults!) should be encouraged to draft advance directives. Makadon, Harvey. The Fenway guide to lesbian, gay, bisexual, and transgender Sexual Abuse --The least reported of all victimization of the elderly--only 30% of those who are victimized report the assault --Often is someone who knows the older adult (Caregiver, fellow facility residents, spouses, --Risk factors: Impairments, Dependency, Frailty --Signs: Agitation, bruising patterns, unexplained STIs, unexplained bleeding, stained underclothing, isolation, depression, agression, etc http://www.helpguide.org/mental/elder_abuse_physical_emoti onal_sexual_neglect.htm http://www.blackburncenter.org/elder_sa.asp Part 4. The Geriatric Patient--What we can learn from Sexual Health? 5 Keys to Good Geriatric Patient Care 1) Avoid assumptions 2) Ask the questions 3) Examine the patient 4) Consider medications 5) Remember there are changes that happen with age and that function trumps chronology every time! Geriatric Concept: Avoid Assumptions For examples... --Married couples or partners may have different expectations and experiences regarding sexuality --Married couples may not be having sex with each other, but still be having sex --People who identify as heterosexual may have sexual relations with same-sex partners and vice versa --People with prior heterosexual partners may now identify as homosexual and vice versa --People may resume sexual activity after many years of abstinence --People who are not having sexual relationships with partners may have masturbate Geriatric Concept: ASK the Questions --If you wait for someone else to bring it up, you'll never talk about it. --Fewer than 15% of new patient visits include a sexual history. --25% of 4th year med students reported feeling embarrassed about taking a sexual history. Sickle MA, Rosenstock H. Taking a sexual history: which questions to ask. The Female Patient.1999;24:33. McCaffee K. A view from the field: the personal challenges and reward of consulting worldwide on sexuality education. SIECUS Report 1998;26:15. Merrill JM, Laux LF, Thonby JI. Why doctors have difficulty with sex histories. South Med J 1990;83:616. Some Useful Phrases Tell me more about yourself. Who are the important people in your life? Are you in a relationship? Are you sexually active? Have your sexual partners been men, women, or both? Do you feel you can be open about this with friends, family, or others? Geriatric Concept: Examine the patient --Use proper draping techniques --Include a “chaperone” if you feel more comfortable and/or the patient feels more comfortable (offer the presence). --Do only the parts of the exam that are necessary --If using a speculum, use a size that is comfortable to the patient, may use just 1 digit for manual exam--can use lubricant** --May have to position patient differently than lithotomy *http://www.ama-assn.org/resources/doc/code-medical-ethics/821a.pdf **https://store.acponline.org/eBizATPRO/images/ProductImages/books/sample%20chapters/PractGyn2_ch01.pdf Geriatric Concept: There are changes with age “The vaginal mucosa becomes attenuated, loses its rugae, and appears pale and almost transparent because of decreased vascularity. A reduction in the amount of pubic hair and loss of subcutaneous fat and elastic tissue causes the labia majora and minora to appear wrinkled.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC33499 20/ Geriatric Concepts: First think medications --Review of medications is key in the care of older adults --As discussed, medications can contribute to ED, anorgasmia, low libido, or vaginal dryness Conclusion: The objectives of this lecture are to --Review the prevalence of sexual behavior and dysfunction in older adults --Introduce treatments for sexual dysfunction and other specific issues related to sexual health and older adults --Emphasize important approaches to geriatric patient care Wrap-up Any additional questions, comments, concerns? Please fill out the index cards to help me improve this lecture. On one side, put things you liked, other side, things to be improved/changed for future lectures. Anything you wanted to know but didn't learn today? THANK YOU!