sexuality in older adults sexuality in older adults

SEXUALITY IN OLDER ADULTS
HEALTHY AGING SEMINAR SERIES
Lynn McNicoll, MD, FAGS
Associate Professor of Medicine
ALPERT
MEDICAL
SCHOOL
DISCLOSURES
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I have no financial relationship with a commercial entity
producing health-care related products and/or services
LEARNING OBJECTIVES
Demonstrate knowledge and understanding of:
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Rates of sexual activity in older adults and determining factors
The differences between normal aging changes in the
reproductive tract and the impact of disease in the older adult
on sexuality
The challenges and barriers to healthy sexual function in the
older adult
Sexually transmitted diseases and the elderly
Challenges with dementia and sexuality
LGBT older adult sexuality
TOPICS TO BE COVERED
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Frequency and type of sexual activity
Illnesses and medications affecting sexuality in
older persons
Concerns specific to women
 Normal aging versus disease
Concerns specific to men
 Normal aging versus disease
WHO DEFINITIONS
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Sexual health is a central aspect of being human throughout
life, and encompasses sex, gender identities and roles, sexual
orientation, eroticism, pleasure, intimacy and reproduction
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Sexuality is experienced and expressed in thoughts, fantasies,
desires, attitudes, values, behaviors, practices, roles, and
relationships.…
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Sexuality is influenced by interaction of social, biological,
psychological, economic, political, cultural, ethical, legal,
historical, and religious and spiritual factors
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Sexuality ≠ Sexual Intercourse
SEX AND AGING
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Humans are living longer; among those >85, there
are 4 men for every 10 women
What happens to sexuality in older age?
Physiological and hormonal aspects influence
sexuality, but more important, the social and
psychological aspects are central, but difficult to
measure or study
Watch out for the Baby Boomers – more likely to
expect sex, have phone sex, leave naughty
messages and have sex in public places
(“Sex in America” AARP July 2005)
BENEFITS OF A HEALTHY SEX LIFE
1. Relieves stress
2. Boosts immunity (↑ IgA)
3. Burns calories (85 cal for
30 minutes)
4. Increases pelvic floor
muscle strength
5. Improves sleep (due to
oxytocin release)
6. Improves CV health; no ↑
risk of death (may ↓MI risk
by half)
7. Boosts self-esteem
8. Improves intimacy
9. Reduces pain
10.Reduces risk of prostate
cancer (if >5 ejaculations
weekly when young)
MYTHOLOGY IS ABUNDANT
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Sex problems are inevitably part of aging
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Nothing can be done, so why bother
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Old people are, or should be, asexual
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Sex in old people is funny
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Sex in old people is disturbing
SEXUALITY AMONG ELDERS
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Older people engage in sex into their 90s, if healthy
and have available partner (if not, solo)
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Most older people are satisfied with their sex lives,
more so than young and middle-aged
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Those with healthy sex lives during youth and
middle age continue in later life
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The need for closeness, caring, and companionship
is life-long
SEXUALITY AMONG ELDERS

Many are active, but don’t tell their children

Major predictors of frequency


Health status – cardiovascular, DM, arthritis

Available partner

Frequency in middle age
Prevalent problems: ♀ libido, lubrication; ♂
Erectile Dysfunction (ED)
Lindau ST et al. N Engl J Med 2007;357:762-74.
SEXUALITY IN 1200 OLDER MEN
Parameter
Ages 55-64
Age > 80
Median Monthly
Frequency of Coitus
3.6
1.3
Desired Monthly
Frequency
7.8
3.9
Masturbation
57%
35%
Sexual Desire
54%
20%
Difficulty with erection
43%
64%
Bortz. J of Gerontology 1999;54A: M237-41
RETIREMENT HOME (ALF) SEX ≥80
Sexual Activity
Men
Women
Sexual intercourse
62%
30%
Physical Intimacy
87%
68%
Arch Sex Behavior 1988, 17; 109
FREQUENCY OF SEXUAL INTERCOURSE
Age
♂
♀
57-64
84%
62%
65-74
67%
40%
75-85
39%
17%
Lindau ST et al. N Engl J Med 2007;357:762-74.
Lindau ST et al. N Engl J Med 2007;357:762-74.
REASONS FOR LACK OF SEXUAL ACTIVITY
Reason
Physical problem
Men
Women
Partner physical
problem
Men
Women
Lack of interest
Men
Women
57-64 yr
65-74 yr
75-85 yr
40%
17%
57%
17%
61%
25%
20%
63%
31%
63%
23%
65%
18%
43%
22%
47%
32%
60%
Lindau ST et al. N Engl J Med 2007;357:762-74.
ILLNESS/CONDITIONS
ILLNESS/
CONDITIONS AFFECTING SEXUALITY
Chronic urinary catheter
Inhibits intimacy and
obstructs access
Chronic pain syndrome
Inhibits libido
Depression
Libido
Vision or hearing loss
Reduces the stimuli for
sexual excitement
Heart and lung disease
Reduces ability to perform
intercourse
Diabetes Mellitus
Causes ED, inhibits orgasm
ILLNESS/CONDITIONS
ILLNESS/
CONDITIONS AFFECTING SEXUALITY
Osteoarthritis
Pain with sexual activity
Stroke
Poor coordination or contractures
Parkinson’s Disease
Poor coordination
Breast Surgery
Self-image and confidence
Prostate/Pelvic
Surgery
Incontinence and Impotence
Incontinence
(fecal or urinary)
Embarrassment
MEDICATIONS THAT AFFECT SEXUALITY
Antihypertensives
ED,
libido
Alpha-Blockers
ED,
libido
Narcotics
ED,
libido
Diuretics
H2 Blockers
Alcohol
Anticholinergics
Embarrassment, leakage of
urine
Anti-androgen ED,
libido, ED
ability to reach orgasm
Penile blood flow
ANTIDEPRESSANTS AND SEXUALITY
SSRIs (Prozac, Paxil, Zoloft,
et al.)
libido, delayed or no
orgasm
Citalopram (Celexa)
Same, but < pure SSRIs
Venlafaxine (Effexor)
Same, but < pure SSRIs
Buproprion (Wellbutrin)
No sexual side effects
Mirtazapine (Remeron)
No sexual side effects
Tricyclic Antidepressants
May
libido (anticholinergic)
PSYCHOLOGICAL OR SOCIAL CONCERNS
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Changes in self-image, mood, body-image
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Feeling less sexy or attractive
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Feeling less feminine or masculine
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Fear of being rejected
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Worries about sexually satisfying one’s partner
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Performance anxiety
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Fear of isolation, guilt, abandonment
SEXUAL DYSFUNCTION IN OLDER WOMEN
Primary Causes
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No able partner
Decreased libido
Altered genital
sensation
↓frequency/intensity
of orgasm
↓ vaginal lubrication
Secondary Causes
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Fatigue/weakness
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Muscle tightness
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Spasm, in-coordination
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Pain during sex
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Small introitus
GYNECOLOGICAL AGING
External genitalia - labial thinning, wrinkling,
pallor, dryness; gray hair; clitoris enlarges
 Breast atrophy, fibrous thickening
 Vagina - atrophy, friability, shortening, shrinkage,
decreased secretions, mucosa thins
 Cervix shrinks; uterus small
 Ovaries should not be palpable 10 years postmenopausal
 Urethra - closing pressure , mucosa atrophies

AGE--RELATED CHANGES IN WOMEN’S
AGE
SEXUAL RESPONSE

Clitoris may require prolonged direct stimulation

Decreased genital engorgement, reduced vaginal
lubrication

Plateau - decreased expansion and vaso-congestion of
vagina

Orgasm - fewer and weaker contractions, occasionally
spastic and painful uterine contractions

Resolution - vasocongestion dissipates rapidly
MENOPAUSE-ASSOCIATED SEXUAL
MENOPAUSECHANGES IN WOMEN
● Decreased
sexual interest
● Decreased
responsiveness
● Decreased
coital frequency
● Increased
urogenital symptoms, often not
discussed with the physician
PAIN WITH INTERCOURSE IN OLDER WOMEN

Due to organic or psychological factors, or a
combination of the two

Most common organic cause: atrophic vaginitis due
to estrogen deficiency

Other causes:
 Localized vaginitis
 Cystitis
 Bartholin's cyst
 Retroverted uterus



Pelvic tumors
Improper angle of entry
Too vigorous thrusting
LIBIDO IN WOMEN

Testosterone-dependent, even in women, rather
than estrogen

Estrogen replacement
 Can improve vaginal lubrication and sense
of well-being
 Has little effect on libido

Ovaries and adrenals are main sources of
androgens in women - ↓↓drop at menopause
TREATING DECREASED DESIRE IN OLDER WOMEN
Cause
Low testosterone postmenopause
Chronic illness
Depression
Relationship problems
Drugs
Therapy
Testosterone is not recommended by The
Endocrine Society
Treat underlying disease
Antidepressant, counseling
Marital therapy
Adjust drug choices, dosing
TREATMENT OPTIONS FOR WOMEN
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Review medications
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Vaginal lubricants (e.g., KY gel, Astroglide)
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Take pain medications prior to sex if pain or
spasm are an issue
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Education concerning techniques and
stimulation exercises
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Sex guides
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Testosterone?
TESTOSTERONE FOR DECREASED
LIBIDO IN WOMEN

Approved by FDA for moderate to severe
vasomotor symptoms not improved with
estrogens alone, not for sexual dysfunction

Available orally in combination with estrogen or
as patch, which is not FDA approved for women

More studies are needed
MALE UROGENITAL AGING
External genitalia - scrotal thinning, pallor,
graying and thinning of pubic hair
● Mild gynecomastia
● Benign prostatic hyperplasia
● Urethra - closing pressure diminished
● Mild changes in semen (↓volume, more
abnormal spermatozoa, less motility); men are
fertile lifelong
● Erectile changes - ↓duration, firmness,
frequency; longer refractory period
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Anatomy (Anxiety?) of the Male Brain
CONCERNS SPECIFIC TO MEN
Normal changes of aging
 Libido
 Vascular insufficiency
 Erectile dysfunction (Impotence)
+ Maintenance or lack of erection
+ Cardiac risk factors
 Prostate surgery and radiation effects on
potency, continence
 Poor physical fitness and endurance

AGE--RELATED CHANGES IN MEN’S SEXUAL RESPONSE
AGE





Excitement - delayed erection; decreased tensing of
scrotal sac; loss of testicular elevation
Plateau - prolonged; decreased pre-ejaculatory
secretion
Orgasm - diminished duration and intensity;
decreased quantity and force of seminal emission
Resolution - rapid detumescence and testicular
descent
Refractory - longer period between erections
VASCULAR CHANGES
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>50% of men >50 with ED have vascular disease as
cause; if prior AMI, 64%
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Arterial & venous insufficiency increase with age
Atherosclerosis, hyperlipidemia, diabetes, HTN and
homocysteinemia contribute to arterial changes
Venous ‘leaks’ become more common with age and
alter venous compression in the penis
Inadequate venous filling and inability to maintain
pressure contribute to erectile disorders
Neurologic disease 2nd commonest (autonomic
dysfunction of DM, PD, primary disorders)
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EVALUATION OF ERECTILE DYSFUNCTION
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Sexual, medical, psychosocial history
Erection quality, ↓libido, orgasmic failure?
Onset and duration of ED
Presence or absence of sleep-associated erections
Check peripheral pulses, autonomic neuropathy,
bulbocavernosus reflex
Palpate for Peyronie’s plaques, testicular atrophy?
Secondary sexual characteristics, gynecomastia?
SPECIFIC TREATMENTS FOR ED
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Yohimbe (Yocon, Yohimex) – renal failure, seizures,
death
Phosphodiesterase inhibitors - sildenafil (Viagra),
tadalafil (Cialis), vardenafil (Levitra) contraindicated
with nitrates, angina, caution with alpha blockers
Alprostadil (Edex, Caverjet) requires
intra-cavernous injection
MUSE – urethral alprostadil
Vacuum mechanical devices
How and Where to Inject
THE LITTLE PILLS THAT COULD
Drug
Onset
Duration of Dosage
Action
Side Effects
Sildenafil
(VIAGRA)
60 min
4 hrs
25-100
mg
Vardenafil
(Levitra)
45 min
4 hrs
5-20 mg
Cadalafil
(CIALIS)
45-60 min 24-36 hrs 5-20 mg
• Transient color
blindness (VIAGRA
only)
• Headache
• Flushing
• Rhinitis
• Dyspepsia
• Contraindicated
with nitrates
• Precaution with
alpha-blockers
SPECIFIC TREATMENTS FOR MEN
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Don’t give up on phosphodiesterase inhibitors on the first
try – 35% of men who fail treatment become responders
after more education (do not take right dose, do not take
long enough before activity, do not stimulate)
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Staying fit - Sexual intercourse is equivalent to a round of
golf, making the bed or gardening
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Psychosocial problems should be addressed by open, frank
discussions – men may not be comfortable talkers
Testosterone: Is There “Andropause?”
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Menopause happens to all women; no
menses, >95% decline in levels of estrogen
“Andropause:” Possible clinical consequences
of decreased T levels (↓1-2%/year after 4050)
ADAM (androgen deficiency in aging male
[>65]) defined so that 50% >65
T has little effect on ED (potency); primarily on
libido
TESTOSTERONE: WHAT IS ANDROPAUSE?2

Body composition – what happens if replace low, lownormal T levels?
Muscle mass <2kg, fat <2.5 kg
+ Little change in strength or physical function
+ No change in insulin sensitivity
+
Bone – replacement in low T men over age 65; conflicting
data on benefit
 Potential harm: prostate (CA, BPH), worsening
cardiovascular disease, liver toxicity, fertility, fluid
retention, sleep apnea, polycythemia
 Conclusion – caution with testosterone replacement,
absence of convincing evidence of efficacy and safety,
substantial risks

If You Decide to Give Testosterone
Increases libido; may improve ED if true
hypogonadism
 Available as IM injection; transdermal patch,
gel
 Before starting, Warn the patient of all
possible side effects; determine which he is
most concerned about and counsel and
screen going forward
 Digital rectal exam to assess prostate;
measure baseline prostate-specific antigen
 Check PSA and hematocrit every 3 months
during first year, then every 12 months

STD AND HIV IN OLDER ADULTS

The # of HIV/AIDS cases among older people in
growing because:
 Older
people know less about HIV/AIDS than younger
people
 Older people use condoms less
 Healthcare providers do NOT discuss it with older patients
and do NOT ask about risky behaviors
 Older people less likely to talk about sex or drug use
SEX IS FUN BUT SHOULD BE ALSO BE SAFE
Use a condom with new partners
 Chose your partners wisely (30% of condoms fail)
 Get PAP test with any new partner, Human Papilloma
Virus is spread sexually and can cause cervical
cancer and anal cancer in men.

SEX AND PERSONS WITH DEMENTIA
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What to do about it, particularly in nursing homes
or other group living?
Especially a problem if partner is not the spouse
Should they be allowed?
Who should provide consent?
Can hyper-sexuality be part of the dementia?
When is a dirty old man a dirty old man?
NEW RELATIONSHIPS IN DEMENTIA
New York Times Article
 Family and staff discomfort
 Supreme Court Justice Sandra Day O’Connor
 Legal and moral implications
 Privacy issues

LGBT (IQQA)
LGBT IN THE ELDERLY
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Sexual Orientation is an enduring emotional, romantic, sexual, and
affectional attraction to another person – Hetero- homo- or bi-sexual
Rate of LGBT is difficult to measure in young and particularly in old
because there are differences in desire, behavior and selfidentification

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E.g. 10% male population show either desire, behavior and self
identification
Among these - 24% desire, behave and self-identify as gay men but 6%
have desire and behavior but do not self-identify, 44% have desire only and
22% have behavior only.
8.6% of women show either desire, behavior and self identification – 59%
desire only, 13% behavior only and 15% all 3.
OLDER LGBT
2-3.5 million Americans
 Diverse group
 Pre-liberation and mostly have internalized homophobia
 33% gay men and 42% lesbians were formerly married to
opposite sex
 More likely to be college graduates and only 25% have
children compared to 86% of non-LGBT older adults
 Gay men have 27% less income
 Higher rates of high blood pressure and diabetes and
mental health problems (45% more likely)

LGBT IN THE ELDERLY
Return to the CLOSET – if they were ever out
 LGBT have fewer children and fewer direct family
caregivers than non-LGBT – 2/3 could not identify
someone to care for them if disabled
 75% of older LGBT live alone compared to 33% of general
older population
 Living in Assisted Living Facilities or Nursing Homes is
particularly scary and dreadful when gay – increased risk
of discrimination and exclusion by other residents and
staff
 Increased risk of depression and suicide

LGBT
L.G.B.T. Aging Projects to train long term care
providers
 New segregated facilities – facilities specifically
catering to LGBT – e.g. Chelsea Jewish Nursing Home
 Increased awareness of sexually transmitted diseases
even in older gay men (1/3 of older gay men have
unprotected anal sex) HIV is now a chronic disease
 Healthy People 2020

http://www.pinknews.co.uk/2011/09/09/london-charityfor-older-lgbt-people-seeks-volunteers/
LGBT SAGE RI – SURVEY OF OLDER LGBT IN RI IN
2005
SAGE – Services and Advocacy for Gay, Lesbian,
Bisexual, and Transgender Elders
 60% in a relationship, 42% previously in heterosexual
marriage
 40% are parents
 40% out to doctors
 Many have experienced or witnessed homophobia in
last year (35% in public places, 11% at work, 10% in
medical setting, 8% at home)

CONCLUSIONS
A healthy sex life in old age is normal, healthy, and
should be encouraged
 Options are available for improving sexuality –
investigate
 Special concerns for older persons with dementia
 Societal changes for LGBT will hopefully extend to the
elderly soon

REFERENCES
1. Lindau ST et al. A Study of Sexuality and Health
among Older Adults in the United States. N Engl J
Med 2007;357:762-74.
2. Kessel B. “Sexuality in the older person”. Age and
Ageing 2001: 121-4
3. Bortz et al. “Sexual function in 1202 Aging Males:
Differentiating aspects”. J of Gerontology 1999;54A:
M237-41.
4. Greengross et al. Living, Loving and Ageing. Age
Concern, 1989. A sex manual.
5. McCartney et al. “ Sexuality and the Institutionalized
Elderly. J Am Geriatr Soc. 1987;35:331-3.
WEBSITES
1. Sexual Health InfoCenter
http://www.sexhealth.org/
2. National Sexuality Resource Center
http://nsrc.sfsu.edu/issues/sex-and-aging
3. Aging and Human Sexuality Resource Guide
http://www.apa.org/pi/aging/resources/guides/s
exuality.aspx