4. Providers:
Are subject to myths and attitudes
of sexuality and aging.
May be insensitive to older
adults needs.
Don’t know how to manage sexual health
issues.
Experience discomfort in managing
sexual issues.
Health Care Provider
Barriers to Sexual Health in Older Adults
A study of 100 patients aged 39 to 86
and their health care providers
revealed that less than 10% of
providers asked patients about
erectile
function, although over 90% of
patients were interested in treatment
(Chitale, et al., 2007)
(Chitale et al., 2007)
5.
Older Males
May fear about the loss of sexual abilities
Older females
may fear their interest is undignified and
disgraceful
Sexuality in elderly
6.
Sexuality is an integral part of the personhood of every human
being in all societies.
Sexual rights are human rights related to sexuality;
Sexual rights are universal, interrelated, interdependent and
indivisible;
Sexual rights protection and promotion should be part of the
daily existence of all individuals;
Sexuality should be recognized as a positive aspect of life
Joys of Sex: Rights of Older Adults
7.
Physiological
Pathological
Behavioural
Psychosocial
- changes in old age can affect sexual functioning
Factors affecting the sexual
functioning in elderly
8.
Decline in libido
Increased time for arousal
More rapid reversion to pre-arousal state
Poor quality of erection in males
Reduced vaginal lubrication in females
Poor quality orgasms
Prolonged refractory period
Changes in sexual cycle
9.
Changes in elderly women
reduced size of vagina & vulva
decreased vascularity & secretions
thinner, more lax vaginal walls
atrophic vaginitis common
Physical changes in genitalia
10.
Menopause
Andropause
Dementia
Chronic illnesses
Sexual abuse
Problematic sexuality
Important topics
11.
? HRT (local and oral)
lubricants
education of woman & partner
Menopause
12.
Physiological factors
Psychological factors
Social and Behavioural factors
Premature Ejaculation is less
Erectile dysfunction
13.
Barriers to intimacy:
Agnosia and other neurological features
Difficulty in identifying social cues
Sexual disinhibition
Caregiver stress
Depression (s)
Dementia
14.
Cardiac disease
stroke
COPD
Diabetes
Arthritis
Surgery
Endocrine Disorders
Physical illnesses affecting sexual
function
16.
Problematic sexuality
Sexually inappropriate behavior and sexual disinhibition, in a clinically significant
level of desire to engage in sexual behavior.
Sexual behaviors of severity and/or duration that cause distress,
disturbance or suffering for close relationships and caregivers.
Persistent, uninhibited sexual behaviors directed at oneself or
inappropriately at others
(Nagaratnam & Gayagay, 2002) (Black et al., 2005)
(Johnson et al., 2006) (Wiseman et al., 2000) (Wick et al., 2005)
17.
Anxiety
Grief
Depression
Late onset Psychosis
Psychiatric illness affecting sexual
functioning
18.
Assessment of sexual health is the first step in developing a
plan of care to fulfill sexual needs of older population.
Health history & review of systems
Drug review
Physical assessment
Assessment for cognitive impairment and impact on sexual health
decision making
Labs - ? Testosterone levels
CT/MRI ? For hypersexual behaviors
Assessment of
19.
… be open-minded and concerned:
Don’t assume there are no concerns
ask direct questions about activity & attitudes
answer honestly
Don’t evade sexual concerns
Suggestions to help talking about it
20.
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!
How to answer patients’
questions?
21.
1) Promote a healthy lifestyle.
2) Compensate for normal age-related changes.
3) Manage pathological diseases that impact sexual
health.
4) Review medications that impact sexual health.
5) Modify environment to facilitate sexual health
functioning.
Management of
Sexual Health Needs
22.
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
If it works for young men can it
work for older men?
23.
Oral testosterone- serious hepatotoxicity
parenteral- may cause fluctuation in levels
transdermal- scrotal or non-scrotal
more physiological levels
scrotal patch causes high DHT
Tx options they might read about on
the Internet?
24.
Compensate for Normal
Aging Changes
The use of oral erectile agents such as
agents such as sildenafil Citrate
(Viagra®), vardenafil HCL
(Levitra®), and tadalifil (Cilalis®)
have greatly aided the onset of ED
that occurs with aging.
There are a number of erectile
agents available in the form of
injectable treatments. These are
effective treatments for ED,
however some are preferred more
by patients than others related to the
extent of pain from the injections.
(Wespes et al., 2007)
(Shah et al., 2007)
25.
Compensate for
Normal Aging Changes
Provide patient teaching on normal aging changes on sexual
function and image.
Discuss need for longer fore-play arousal time to compensate for
normal aging changes.
Consider alternative forms of intimacy when sexual intercourse is
too uncomfortable or not possible.
Use it or lose it.
26.
Depression & Sexual Health
A sample of 30 depressed patients with a mean age of 52 was randomized to
receive either T enanthate (testosterone) 200 mg or sesame-seed oil (placebo).
Self-reported sexual functioning improved in both groups, but no significant
differences were found between groups
CATCH 22
• Treatment of depression may help to improve libido and
sexual dysfunctions such as orgasmic disorders.
• However, medications to treat depression, often impact
sexual function by lowering libido and causing orgasmic
disorders.
(Siedman & Roose, 2006)
27.
Pharmacological Treatment
of Hypersexual/Problematic sexual Behavior
Controversial, ethical issues
Hormonal agents – decrease testosterone
Anti-androgens
Side effects include sedation, weigh gain, fatigue, hot and cold flashes, depression, loss of
body hair and mild diabetes.
Gonadotrophin-releasing hormone
side effects associated with these medications include hot flashes decreased erectile function
and libido and irritation at injection site.
Estrogens
risk of cardiovascular side effects as well and increased fluid retention, gastrointestinal effects
require caution.
Level IV
Chitale, S., Collins, R., Hull, S., Smith, E., & Irving, S. (2007). Is the current practice providing an integrated approach to the management of LUTS and ED in primary care? an audit and literature review. J.Sex.Med., 4(6), 1713-1725.
Level IV
Nagaratnam, N., & Gayagay, G. (2002). Hypersexuality in nursing care facilities—a descriptive study. Archives of Gerontology and Geriatrics, 35(3), 195-203.
Level V
Black, B., Muralee, S., & Tampi, R. T. (2005). Inappropriate sexual behaviors in dementia. Journal of Geriatric Psychiatry & Neurology, 18(3), 155-162.
Level V
Johnson, C., Knight, C., & Alderman, N. (2006). Challenges associated with the definition and assessment of inappropriate sexual behavior amongst individuals with an acquired neurological impairment. Brain Injury, 20(7), 687-693.
Level V
Wiseman, S. V., McAuley, J. W., Freidenberg, G. R., & Freidenberg, D. L. (2000). Hypersexuality in patients with dementia: Possible response to cimetidine. Neurology, May(2), 2024.
Level V
Wick, J. Y., & Zanni, G. R. (2005). Disinhibition: Clinical challenges in the long-term care facility. The Consultant Pharmacist, 20(12), 1006-1018.
Level II
Wespes, E., Moncada, I., Schmitt, H., Jungwirth, A., Chan, M., & Varanese, L. (2007). The influence of age on treatment outcomes in men with erectile dysfunction treated with two regimens of tadalafil: Results of the SURE study. BJU International, 99(1), 121-126.
Level IIShah, P. J., Dinsmore, W., Oakes, R. A., & Hackett, G. (2007). Injection therapy for the treatment of erectile dysfunction: A comparison between alprostadil and a combination of vasoactive intestinal polypeptide and phentolamine mesilate. Current Medical Research and Opinion, 23(10), 2577-2583.
Level II
Seidman, S. N., & Roose, S. P. (2006). The sexual effects of testosterone replacement in depressed men: Randomized, placebo-controlled clinical trial. Journal of Sex & Marital Therapy, 32(3), 267-273.