Evidence-Based Reviews

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

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A sexual history is an essential part of the comprehensive psychiatric evaluation


 

References

Recent studies suggest that most older adults main­tain sexual interest well into late life; many, however, experience sexual dysfunction. This article provides psychiatric practitioners with current information regard­ing sexuality and aging, as well as psychiatric and systemic medical comorbidities and sexual side effects of medi­cations. Practice guidelines for assessing and managing sexual dysfunction have been developed for use in many medical specialties, and such guidance would be welcome in psychiatric practice.

This article addresses the myth of “geriatric asexuality” and its potential impact on clinical practice, the effects of age-related physiological changes on sexual activity, the importance of sexuality in the lives of older adults, and sensitive questions clinicians can pose about geriatric sexu­ality. We also will discuss:
• the importance of including a sexual assessment in the comprehensive psychiatric evaluation
• recognizing sexual dysfunction
• providing appropriate management within a multi-disciplinary, collaborative approach.


Sexuality after 65

Regardless of age, sexual activity can provide a sense of com­fort and elicit a positive emotional and physical response.1 Hillman2 defined human sexuality as any combination of sex­ual behavior, emotional intimacy, and sense of sexual identity.

Sexuality in the aging population gen­erally is an understudied area, obscured by the myth of “geriatric asexuality” and subject to numerous psychosocial vari­ables.1 Previous research, focused on a bio­logical perspective of sexuality, has largely overlooked psychological and social influ­ences.3 It has been assumed that, with age, physical and hormonal changes or chronic illness ordinarily reduce or eliminate sex­ual desire and sexual behavior.3 However, the majority of older adults (defined as age ≥65) report a moderate-to-high level of sexual interest well into late life.1,3

Sexual function remains a subject often neglected in psychiatry. Sexual dysfunc­tions, as described in the DSM-5,4 do not include age-related changes in sexual func­tion. In addition to physiological changes, sexual difficulties can result from relation­ship strain, systemic medical or psychi­atric disorders, and sexual side effects of medications.


CASE REPORT
Mr. C, age 71 and married, is being treated for a major depressive episode that followed a course of shingles and persistent posther­petic neuralgia. Medications are: escitalo­pram, 20 mg/d; pregabalin, 150 mg/d; and ramipril, 5 mg/d. Mr. C is physically active and involved in social activities; he has no substance use history. He attends clinic visits with his wife.

Mr. C reports that despite significant improvement of his depressive and pain symptoms, he now experiences sexual dif­ficulties, which he seems hesitant to discuss in detail. According to his wife, Mr. C appears to lack sexual desire and has difficulty initi­ating and maintaining an erection. She asks Mr. C’s psychiatrist whether she should stop her estrogen treatment, intended to enhance her sexual function, given that the couple is no longer engaging in sexual intercourse.

Mr. C admits to missing physical inti­macy; however, he states, “If I have to make a choice between having sex with my wife and getting this depression out of my head, I’m going to pick getting rid of the depres­sion.” Mrs. C says she is becoming dissatisfied with their marriage and the limited time she and her husband now spend together. Mr. C’s psychiatrist suggests that Mr. C and his wife undergo couples counseling.


Physiological changes with aging

In both women and men, the reproductive system undergoes age-related physiologi­cal changes.

Women. In women, the phase of decline in ovarian function and resulting decline in sex steroid production (estradiol and pro­gesterone) is referred to as the climacteric, with menopause being determined retro­spectively by the cessation of a menstrual period for 1 year.5

Menopausal symptoms typically occur between age 40 and 58; the average age of menopause is 51.6,7 Both estradiol and pro­gesterone levels decline with menopause, and anovulation and ovarian failure ensue. A more gradual decline of female testoster­one levels also occurs with aging, starting in the fourth decade of life.8

Clinical manifestations of menopause include vasomotor symptoms (ie, “hot flushes”), sleep disturbances, anxiety and depressive symptoms, decreased bone min­eral density, and increased risk of cardio­vascular disease.6,7 Loss of estrogen as well as continued loss of testosterone can result in dyspareunia because of atrophy and decreased vulvar and vaginal lubrication, with sexual excitement achieved less quickly, and a decreased intensity of orgasm.7

Men. Research has shown that testosterone levels are highest in men in the second and third decades, with a subsequent gradual decline.9 Older men with a low testosterone level are described as experiencing “late-onset hypogonadism,” also known by the popularized term “andropause.”10 This is attributed to decreased activity at the tes­ticular and hypothalamic levels.10

Nonetheless, only a small fraction of older men with confirmed androgen defi­ciency are clinically symptomatic.11,12 Low testosterone is associated with decreased libido; it can hinder morning erections, contribute to erectile dysfunction, and result in erections that require physical stimulation.13

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