How to begin. As a starting point to taking a sexual history, an open-ended invitation for the geriatric patient to share information may be best, such as “What would you like to tell me about your sexual life?” See further suggestions (Table 1) and examples of more detailed questions to ask once a dialogue has been initiated (Table 2). Additional factors that may contribute to sexual dysfunction are presented in Table 3.1,27,29,30
CASE CONTINUED
In Mr. C’s case, an assessment of his sexual history, including risk factors for sexual dysfunction, is completed. Results from laboratory investigations, including a total testosterone level, are within normal limits.
Mr. C asks about using medications with fewer sexual side effects (he has been taking 3 medications that can contribute to sexual dysfunction). A gradual cross-taper of escitalopram, 20 mg/d, to mirtazapine, 45 mg/d, is implemented, along with tapering pregabalin to 50 mg/d.
Mr. C’s psychiatric and pain symptom improvement is maintained. He notices a boost in his sexual desire but has minimal improvement in erectile dysfunction. He is encouraged to speak with his primary care physician about an antihypertensive agent with less impact on sexual function, as well as therapeutic agents for erectile dysfunction; these, he declines.
At a subsequent visit, Mr. C reports feeling less apprehension about sexual performance. He is now willing to consider further medication options with his primary care physician, and agrees to a recommendation for couples psychotherapy.
As illustrated in Mr. C’s case, the recommended sexual assessment and management strategies to consider at a minimum in psychiatric practice are listed in Table 4.
STI risk in geriatric patients
The risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), often is overlooked in sexually active older adults. Although STIs are more common among younger adults, there is recent evidence of increased incidence in the geriatric population31 (with the highest risk of incident HIV and some STIs in older men who have sex with men32). These increased rates can be explained, at least in part, by:
• older men being less likely to use a condom during sexual activity
• promotion of viral entry in older women through a drier, thinner vaginal wall
• increased longevity of HIV-positive persons.31
Routine STI screening is not warranted in all older adults, but education and prevention strategies in sexually active seniors who are at greater risk of STIs are recommended. Particularly, clinicians should seek opportunities to discuss risk factors and safe sex practices (eg, using condoms, limiting number of sexual partners, practicing good hygiene, engaging in preventive care), and provide behavioral counseling where appropriate.31,33
Additional considerations in geriatric sexuality
Because psychiatric and systemic medical conditions can hinder sexual function, it is essential to identify and manage these conditions. Several neuropsychiatric disorders, including mood and neurocognitive disorders, can not only cause sexual dysfunction, but also can raise ethical dilemmas for clinicians, such as reduced decisional capacity in cognitively impaired patients to consent to sexual activity.1,34
In some patients, psychological, environmental, and pharmacological treatment options may help. A phosphodiesterase type 5 inhibitor for erectile dysfunction can be prescribed by the primary care physician, a psychiatrist, or another specialist, depending on the physician’s expertise and comfort level.
Sequencing of sexual dysfunction. Notably, there is a common paradox in mood disorders. Decreased sexual interest or performance may represent an aspect of anhedonia associated with depression, whereas sexual dysfunction could also result from medication use (particularly that of serotonergic antidepressants, such as selective serotonin reuptake inhibitors and serotonin-norepinephrine inhibitors), even as other depressive symptoms improve. Therefore, it is critical to analyze sequencing of sexual dysfunction—as part of the presenting mood symptoms or dysfunction induced by antidepressant treatment.
Geriatric sexuality in the digital age. Because older adults represent a rapidly growing segment of digital device users,35 Internet use is likely to play a role in the future of sexuality and “digital intimacy,” in that older adults can engage in online sexual activities. The Internet also can be a tool to access medical education.
Related Resources
• Burghardt KJ, Gardner KN. Sildenafil for SSRI-induced sexual dysfunction. Current Psychiatry. 2013;12(4):29-32,A.
• Maciel M, Laganà L. Older women’s sexual desire problems: biopsychosocial factors impacting them and barriers to their clinical assessment [published online January 5, 2014]. Biomed Res Int. 2014;2014:107217. doi: 10.1155/2014/107217.
Drug Brand Names
Bupropion • Wellbutrin, Zyban Mirtazapine • Remeron
Carbamazepine • Tegretol Oxcarbazepine • Trileptal
Clonidine • Catapres Phenobarbital • Luminal
Donepezil • Aricept Phenytoin • Dilantin
Escitalopram • Lexapro Pregabalin • Lyrica
Gabapentin • Neurontin Ramipril • Altace
Lamotrigine • Lamictal Rivastigmine • Exelon
Lithium • Eskalith, Lithobid Trazodone • Desyrel
Memantine • Namenda Valproic acid • Depakote