Download Sexual Health in the Older Patient

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!