When it’s time for ‘the talk’: Sexuality and your geriatric patient

Notably, erectile dysfunction involves several other etiologic factors: psychiatric (eg, relationship difficulties, depression), neurogenic (eg, spinal cord injury), endo­crine (eg, hyperprolactinemia), arteriogenic (eg, hypertension, type 2 diabetes mellitus), and drug-induced (eg, antidepressants, antihypertensives).¹⁴ A low testosterone level also has been associated with potential cognitive changes, decreased bone mineral density, metabolic syndrome (eg, increased risk of type 2 diabetes mellitus), and cardio­vascular mortality.¹⁰

Effects on sexual activity. How much age-related physiological changes impact sexual practices in the geriatric popula­tion is uncertain. A study following 3,302 women through menopause over 6 years found some decline in sexual activity; how­ever, this decline was not associated with increased sexual pain, decreased desire, or lack of arousal.¹⁵ Men continue to find ways to remain sexually active despite physiolog­ical changes (eg, erectile difficulties), but the etiology of sexual dysfunction in later life remains multi-modal, involving physical, psychological, and relational factors.^16,17

Sexual practices in older adults
Researchers for the National Social Life, Health, and Aging Project (NSHAP) have examined sexual activities, behaviors, and problems in >3,000 older community-dwelling men and women across the United States, using information collected from in-home interviews.18 This study found that sexual activity, defined as any mutually voluntary sexual contact with another person, declines with age; how­ever, even in the oldest age group (age 75 to 85), 39% of men and 17% of women reported being sexually active in the last 12 months. Among these persons, 54% reported sexual activity at least 2 times per month; 23% reported having sex at least once a week; and 32% reported engaging in oral sex. Partner availability predicted sexual activity.

Respondents with self-reported poor physical health were more likely to experi­ence sexual problems (eg, difficulty with erection or lubrication, dyspareunia, and lack of pleasure). The most commonly reported reason for sexual inactivity in those with a spouse or other intimate partner was the male partner’s poor physical health.¹⁸

A longitudinal study, part of the Women’s Healthy Ageing Project, examined changes in sexual function at late menopause com­pared with early menopause. Although the researchers also found an age-related decrease in sexual activity, 50% of their late-menopause respondents (mean age, 70; range, 64 to 77) still reported sexual activity in the previous month, with 35% of this subgroup reporting sexual activity at least once a week; 83% reported sexual thoughts or fantasies.¹⁹ Availability of a partner, absence of a history of depression, moder­ate (compared with no) alcohol consump­tion, and better cognitive function were significantly associated with a higher level of sexual activity.¹⁹

In the Successful Aging Evaluation study, conducted in San Diego County, California, community-dwelling older partnered adults age 50 to 99 (mean age, 75) were surveyed about their sexual health after a cogni­tive screen by telephone²⁰; rating scales for depression, anxiety, and physical function also were included. Results included 41% of men and 35% of women reporting sexual activity at least once a week, and only 21% of men and 24% of women reporting no sex­ual activity in the previous year. Depressive symptoms were most highly correlated with lack of sexual activity.²⁰

Overall, these studies reveal that posi­tive physical and mental health, access to a healthy partner, and a positive attitude toward sex are correlated with sexual activ­ity in later life, whereas barriers to sexual activity include lack of a healthy sexual partner, depression, and chronic systemic medical illnesses, such as coronary artery disease or type 2 diabetes mellitus.^13,17,21-24 Sexual activity and satisfaction have been positively associated with perceived general well-being and self-esteem.^25,26 Conversely, sexual difficulties secondary to disease can be a source of distress for couples.²⁷

Possibly overlooked? It is important to note that sexuality itself is a subjective area. Psychological intimacy is a universal phe­nomenon, and its physical expression may evolve as couples accommodate to age-related bodily changes. Means of achieving physical closeness, other than intercourse (eg, intimate touching, hand holding, kiss­ing, or even acts of caretaking), may not be adequately captured in studies that look specifically at sexual activity.

Taking a sexual history in a geriatric patient
Because sexuality can be an uncomfort­able topic for geriatric patients to discuss, sexual problems in this population often go unrecognized. It has been suggested that psychiatrists are more likely to inquire about sexual activity in middle-aged patients than geriatric patients with the same psychiatric presentation—perhaps illustrating a bias against taking a sexual history from a geriatric patient.²⁸ However, because many older patients can experi­ence depression or anxiety disorders in relation to normal sexual changes or sex­ual dysfunction within the context of their intimate relationships, it is essential to bring these issues to light.

Although a sexual history may not be the focus of a first clinical encounter, consider making such an assessment at a relatively early stage of patient care. The importance of such dialogue is 2-fold:
• It demonstrates to the patient that talking about sexuality in a respectful and empathic manner is appropriate and can encourage patients to communicate more effectively about sexuality with clinicians and with sexual partners.
• It helps elicit medical information needed to make an accurate diagnosis and provide adequate management.