Download SEXUAL FUNCTION AND DYSFUNCTION IN OLDER PERSONS

Sexuality in Older
Adults
Sexuality and Reproduction
Mary McDonald, MD
Definition of Sexuality
The psychological and behavioral
aspects of sexual expression in
complex organisms.
Old People Have Sex
There has been relatively little
research on sexuality in later life,
particularly among persons over 60
years of age.
Why is that?
What the Stats say
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Recent study by AARP reveals that many people
remain sexually active into their 70s.
The Janus report found that in patients > 65, 69%
of men and 74% of women report some form of
sexual activity at least weekly
Breshneider and McCoy study of patients aged
80-102, 72% of men and 30% of women engage
in sexual intercourse
Societal/Cultural Views
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Negative images and stereotypes abundant
in US culture
Sexuality in older persons seen as
unseemly, even unnatural
Sex is for beautiful, young people
Leaves many older adults feeling asexual
“we’re supposed to be asexual, and
those who refuse to be so are branded
dirty old men”
DeLamater and Sill
Another Misconception
Vaginal intercourse is the only “real sex”
Hands and mouths are reliable; penises and
vaginas are not
DeLamater and Sill
Decline in Sexual Activity
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Medications
Illness
Urinary incontinence
Partner availability
Relationship problems
Above reasons likely contribute to decline
more than aging itself
Medications Interfering with Sexual
Functioning
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Anti-hypertensive's
Diuretics
Anti-arrhythmics
Opiates
Antihistamines
Anti-cholinergics
Stimulants
antidepressants
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Lipid-lowering agents
Anti-estrogens
Anti-androgens
Exogenous hormones
Also: alcohol and
tobacco
Illnesses Interfering with Sexual
Functioning
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Vascular Disease
Heart Disease
Diabetes
Arthritis
Depression
Cardiovascular Disease and Sexual
Functioning
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Inadequate vascular supply to pelvis
problematic for arousal
Poor exercise tolerance, dyspnea on
exertion, exertional angina
Many cardiovascular meds can interfere
with normal sexual response
Diabetes and Sexual Functioning
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Neuropathic changes to pelvic/genital
nerves can interfere with normal functioning
Highly susceptible to polypharmacy
Arthritis and Sexual Functioning
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Joint pain and lack of flexibility can interfere
with sexual positioning
Narcotic pain medication can interfered
with normal sexual response
Depression and Sexual Functioning
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Generalized anhedonia interferes with
sexual desire
May interfere with relationships, thus a
partner for sexual activities
SSRI, TCA antidepressants interfere with
normal sexual functioning
Urinary Incontinence and Sexual
Functioning
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Women report urinary incontinence
interferes with sexual fulfillment
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Low libido
Fear of urine leakage during sex
Depression
Embarrassment
Tannenbaum, et al
Partner Availability
In the U.S, there are 26.6 million men and 33
million women over the age of 55
Only 74% of the men and 50% of the women
are married and living with a spouse
Smith
Approach to Sexual Interview
EVALUATE your own attitudes, feelings, values
regarding sexuality
 DEMONSTRATE sensitivity to patients beliefs and
values
 AVOID Medical Jargon
 REMAIN NONJUDGMENTAL
 IDENTIFY when the problem began, how it
developed (gradually or suddenly),
and what factors make it better or worse.
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Approach to Sexual Interview
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ASK the patient to describe his/her behavior,
emotional reactions, and thoughts from start to
finish during a recent sexual experience both with
and without a partner
OBTAIN a complete medical history to identify
biomedical and psychiatric illnesses, trauma,
surgery or medications.
ASSESS psychosexual and relationship history.
Approach to Sexual Interview
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EXPLORE options for non-coital and/or
non-genital sexual expression
DISCUSS sexually-transmitted infections,
including HIV, and review safe sex
guidelines
Nusbaum, et al
Communication-Older Woman
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More likely than men to seek medical care
for sexual problems
Easier if physician initiates the discussion
A sense of caring and a continuous medical
relationship facilitates
Little difference if physician is male or
female
Communication- Older Men
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Overall less likely to make appointment to
discuss any particular health issue
Health-seeking behaviors often initiated by
women in their lives
Basic Sexual Counseling for Older
Adults
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Avoid sexual interaction at times of day when
pain, fatigue, or stress are highest
Engage in ample non-genital and genital touch
Include non-demand touch (massage, handholding) that is not linked to sexual activity
Discuss varying sexual positioning to reduce pain
and maximize sexual stimulation for each member
of the partnership
Basic Sexual Counseling for Older
Adults
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Take turns at giving both sexual pleasure as
well as non-demand touching
Limit alcohol and tobacco use
Expand sexual repertoire to include erotic
literature, sexual lubricants, fantasy, selfstimulation
Talk more with one’s partner about what is
pleasurable
Nusbaum, et al
Sexual Arousal Cycle
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Desire
Arousal
Plateau
Orgasm
Resolution
Desire Phase
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Androgen levels decrease in men and
women with age
Study by DeLamater et al reveals that not
until age 75 or older that the majority of
women and almost a majority of men report
a low level of sexual desire
Exogenous hormones, antidepressants and
some diabetes meds may interfere
Arousal and Plateau Phase
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Requires intact parasympathetics and
vascular system
Diminished estrogen in postmenopausal
women can lead to decreased lubrication
Study by Feldman, et al reveals up to
52% of men (age 40-70) had some
degree of erectile dysfunction.
Orgasm
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Older women remain capable of multiple
orgasms but sensation may be lessened
due to decreased muscle tone
Force and volume of male ejaculation may
diminish and may not occur with every
sexual encounter
Rapid ejaculation less problematic but
prolonged ejaculation more common
Resolution
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Return to pre-excitement phase occurs
more rapidly in older men and women
Refractory period significantly increases in
older men
The Older Gay and Lesbian Patient
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May be resistant to volunteer information
on their sexuality
Aged prior to sexual revolution
Communication aided by nonjudgmental,
accepting stance
Gender neutral language, “partner”, may be
helpful
Sexuality in Nursing Homes
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Sexual expression is often not fostered, but
restrained
Personal values of NH staff may supersede
rights of patients
Sexual expression often labeled, “sexually
inappropriate behavior”
By law, facilities must accommodate
privacy needs of consenting adults
Ethical/Legal/Financial Concerns in
NH
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Ability of both partners to give consent for
sexual activity
Family disapproval
Staff/resident social comfort
Lack of adequate space for privacy
STDs in Older Adults
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Grossly overlooked by medical
professionals
Low levels of condom use in older adults as
often associated with pregnancy prevention
only
Older men may have multiple partners
available. By age 85, women outnumber
men by 3:1
STD in Older Adults
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Patients over the age of 50 account for 10% of
reported HIV cases
In 1997, patients over the age of 55 accounted
for
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4% of primary and secondary syphilis cases
1% of cases of gonorrhea
Prevalence of HSV-2 increases with increasing
age
Calvet and Bolan
References
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Bretschneider JG, McCoy NL. Sexual interest and behavior in healthy 80 to
102 year olds. Arch Sex Behav 1988;17:109-129.
Calvet, Helene M and Bolan, Gail. STDs in Older Adults: the Need for
Increased Awareness. Clinical Geriatrics. 2000
DeLamater, John D; Sill, Morgan. Sexual Desire in Later Life. The Journal
of Sex Research. May 2005
Feldman, HA, et al. Impotence and Its Medical and Psychosocial
Correlates: Results of the Massachusetts Male Aging Study. J Urol 2994
Janus SS, Janus CL. The Janus Report on Sexual Behavior. New York:
John Wiley & Sons, 1993;25.
Nusbaum, Margaret R.H, DO,MPH, et al. Sexual Health in Aging Men and
Women. The Psychiatric Consultant
References
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Smith,D.(2003). The older population in the United States; March 2002.
Washington, DC: United States Census Bureau, Current Population
Reports
Tannenbaum, MD, MSc, et al. The Relationship Between Sexual Activity
and Urinary Incontinence in Older Women. JAGS, 2006