Geriatric Sexuality

1
Geriatric Sexuality

• Older people were young once too!
• C. Frank CCFP Oct 02

2
Outline

• Myths and expectations
• research- old and new
• what changes as we age
• Talking to older patients about sexuality
• some specific topics

3
The writers view

• Wives are young mens mistresses, companions for
  middle age and old mens nurses. Francis
  Bacon
• Sexuality in the elderly is a dark continent
  that most people, including physicians, prefer
  not to think about. J. LoPiccolo

4
The writers view...

• Forty years of romance makes a woman look like a
  ruin, 40 years of marriage makes a woman look
  like a public building. Oscar Wilde
  
• These people are just happy to be alive. Anon

5
The medias view...
6
What is sexuality?

• too often sexuality is equated with the ability
  to have or the frequency of intercourse
• sexuality encompasses self, interactions with
  others, and many levels of expression and
  affection

7
What do you think of when you think of elderly
sex?

• ???

8
Beliefs about sex aging

• Current elderly were Victorians when young
• sexual desire goes with age
• older women who enjoy sex were nymphomaniacs
  when younger
• the dirty old man
• elderly are not desirable, desirous, capable

9
More mythology viewpoints...

• Physiological changes sexual dysfunction
• cute, disgusting, troublesome
• physical illness obviates sex sexuality
• Viagra leads to divorces!

10
How do older people view sexuality?

• I was told nothing until my wedding night and my
  husband explained it.. For two solid weeks I was
  in a state of shock.
• despite initial naivete women describe good early
  attitudes towards sex
• minimal change in attitude with aging

11
Talking with older women...

• The longer you live you start to realize life
  is too short and sex is probably one of the last
  things to go.
• You are always a sexual being, until you die.
• You know, just because we are old doesnt mean
  that when I see a nice grey-haired older man.. I
  take another look.

12
Apart from myths, what are other barriers

• Physiological changes
• lack of privacy
• illness impotence
• lack of a partner
• negative attitudes from staff physicians
• feeling of unattractiveness
• guilt widows syndrome

13
Thinking about barriers

• My husband got used to me after 50 years if I
  was to start up with a new man nowif we could do
  it in the dark with our clothes on
• There are no single guys out therenot at our
  age.

14
Why do older people stop having sex?

• For the same reasons they stop riding a bicycle
• fear of falling off (ill health)
• afraid of looking ridiculous
• lack of a bicycle

15
What research tells us...

• The Kinsey report general decline interest
  activity
• MJ sharp decline in interest after age 60
• other generally gloomy results

16
Newer results...

• The Starr-Weiner report
• 97 liked sex
• 91 approved of unmarried/widowed aged having sex
• quality more important than frequency!
• Women in survey had intercourse 1.4/week

17
Even educated fleas do it...

• Large proportion of seniors sexually active
• 54 of married men women
• 65 of women over age 70
• Netherlands 34 of women surveyed enjoy sexual
  activity most of time
• Vs. 70 of premenopausal women

18
Defining sexuality more clearly than Clinton

• Women age 80-102
• 25 had regular partner
• touching and caressing 64
• masturbation 40
• intercourse 30
• activities often dependent on older partner

19
Physiology the pleasure principle

• Women
• reduced size of vagina vulva
• decreased vascularity secretions
• thinner, more lax vaginal walls
• atrophic vaginitis common
• libido declines but rarely disappears

20
What problems may women report

• 43 of older Swedes reported vaginal dryness
• 10 vaginal burning
• urinary incontinence may occur
• dyspareunia
• decreased orgasm (30)

21
How does the sexual cycle change?

• Excitement!
• Decreased vasocongestion, lubrication, delayed
  arousal
• Plateau
• expansion of vaginal barrel, orgasmic platform,
  clitoral retraction

22
Cycle changes...

• Orgasm
• shorter fewer contractions
• may be painful
• Resolution
• more rapid reversion to pre-arousal state

23
What changes for men?

• Changed libido
• erectile function
• increased need for stimulation
• inadequate rigidity associated with risk factors
• decreased ejaculatory demand
• decreased ejaculatory power
• prolonged refractory stage (up to one week)

24
Talking to your granny about SEX!

• Important indicator of comorbidities
• if done appropriately, not offensive
• 91 over age 65 felt history-taking was
  appropriate
• remember that identification education very
  successful
• sexual abuse can still occur

25
Hearing from the AARPs

• Health-providers should help us feel comfortable
  talking about sex
• dont be afraid or embarrassed
• help us break the ice
• offer permission to express feelings needs

26
Suggestions to help talking about it

• be open-minded and concerned
• dont assume there are no concerns
• ask direct questions about activity attitudes
• answer honestly
• dont evade sexual concerns

27
More from the AARP...

• should treat older adults with respectful
  non-judgemental attitude
• see us as individuals with sexual needs
• accept us gay, straight, bisexual
• can provide advice suggestions

28
What did Kingston women have to say?

• So, hows your sex life? not a great line
• valid question if an explanation is given
• would talk to their MD if something specifically
  wrong
• laymans terms, avoid making patient feel
  complaint insignificant

29
Getting better informed about specific topics

• Menopause
• ED
• dementia
• sexual abuse
• chronic illnesses

30
Menopause just a few controversies

• Treatments
• HRT (local and oral)
• education of woman partner
• ?testosterone ?Viagra
• lubricants
• education about male partners aging changes

31
The myth of male menopause?

• Controversial!
• ?aging associated with lower sex steroid levels
• levels of binding globulin increases
• pituitary, adrenal and testicular causes
• less dramatic less rapid than with women

32
What might it mean?

• testosterone likely plays smaller role in ED
• many men try androgens to help erectile
  dysfunction
• frailty osteoporosis, decreased muscle mass

33
How to look for it?
34
Viagra an interesting sociological study

• Pfizer stock is a star!
• US army spending on it

35
Listening to Viagra

• Dr. Ian Osterloh may be one of the most
  important men in American history, if not world
  history

36
Viagrathe first of many

• inhibits phosphodiesterase
• elevates serum levels of cyclic guanosine
  monophosphate
• effect is on erectile dysfunction not libido

37
Viagrathe first of many
38
How to use it?

• taken orally 50 mg 1 hour before planned
  intercourse
• achieve erections in up to 85 of men
• be aware of safety concerns- good assessment of
  comorbidities

39
Who to be cautious with

• Active coronary ischemia
• active CHF
• hypotension/hypertension
• liver/renal failure
• interacts with cimetidine, erythromycin
• frequent users!!!

40
New kids on the block?

• Vardenefil - can be taken with food!
• tadalafil
• apomorphine- ??2003

41
Dementia Sexuality

• Barriers to intimacy
• agnosia
• social cues
• sexual disinhibition
• caregiver stress
• depression (s)

42
Sexual abuse and older people

• Fits definition of Elder Abuse
• remote history of abuse
• depression
• anxiety
• adjustment disorders
• resource limitations

43
Sexuality and medical conditions

• Cardiac disease
• stroke
• COPD
• Diabetes

44
Ae fond kiss and then we sever
45
Sexuality and the older adult

• Be aware of the issue
• knowledge of aging changes important
• comfort in communication
• expertise in specific topics helpful

46
If its not too effective, is it safe?

• Weight gain, gynecomastia, sleep apnea
• MI, stroke
• altered lipids, ? Polycythemia
• prostate cancer?

47
How to answer patients questions?

• Consider screen for testosterone,highest level in
  AM
• if low, check FSH, LH, prolactin
• could consider Tx for libido problems
• not likely great for lost vigor and soft body!

48
If it works for young men can it work for older
men?

• Testosterone given IM to 13 men 57-76 years old
  with low serum testosterone
• increased lean body mass but no change in body
  fat, grip strength, bone parameters
• increased PSA
• less clear benefit than in younger men

49
Tx options they might read about on the Internet?

• Oral testosterone- serious hepatotoxicity
• parenteral- may cause fluctuation in levels
• transdermal- scrotal or non-scrotal
• more physiological levels
• scrotal patch causes high DHT