Time for “the Talk”—Again

As evidence emerges that many individuals maintain active sex lives well into their later years, physicians are being challenged to look past stereotypes and discomfort to broach to their older patients such sensitive topics such as sexual dysfunction and the risk of sexually transmitted diseases.

Emerging evidence over the past decade suggests that many older adults continue to have sex, many experience sexual dysfunction, and some are at risk of sexually transmitted infections. Yet many physicians never discuss these important health issues with their older patients.

In 2007, Stacy Tessler Lindau, MD, of the University of Chicago Pritzker School of Medicine, and colleagues published data from the largest US survey of sexuality in older adults to date, which included interviews with nationally representative sample of more than 3000 adults aged 57 to 85 years (Lindau ST et al. N Engl J Med. 2007;357[8]:762-774). Nearly three-quarters of those aged 57 to 64 years were sexually active and more than half of the cohort of 65- to 74-year-olds and more than one-quarter of individuals older than 75 years continued to have sex.

Of the sexually active respondents, more than half reported at least 1 bothersome sexual problem, most commonly low desire, difficulty with vaginal lubrication, and inability to climax (among women) and erectile difficulties (in men). Yet only 38% of the men and 22% of then women surveyed reported having discussed sex with their physician since they were 50 years old.

“We did this study to give physicians information that would help them open the door for conversations about sexuality with older adults,” said Lindau. She explained that some physicians may hesitate to broach the topic because they feel they do not have enough information or that doing so might cause their patients distress.

Older patients, however, are receptive to having such discussions. A survey of adults older than 50 years visiting primary care providers or genitourinary medicine clinics in Sheffield, England, found that most patients who had discussed sexual concerns with a physician were satisfied with the consultation but that older patients were less satisfied (Gott CM. Health Soc Care Community. 2001;9[2]:72-78). Most of the individuals reported having received little information about HIV/AIDS, and 25% indicated they would like more information. A second survey of 55 women aged 58 to 93 years by Lindau and colleagues found that the women felt their physicians should discuss sexual issues (Lindau ST et al. J Womens Health [Larchmt]. 2006;15[6]:747-753).

But the literature suggests that if physicians do not start the discussion, patients will not either, Lindau said. And opportunities to identify sexual health issues can be missed. For example, Lindau and colleagues have documented that among women with genital cancers, those whose physicians discussed the potential impact of cancer treatment on their sexual function reported better current sexual function than did women whose physicians did not discuss such ramifications.

Further analysis of data from the large US survey of sexuality in older adults suggests that poor physical or mental health, as well as dissatisfaction with their relationship, are important factors associated with sexual dysfunction in older adults (Laumann EO et al. J Sex Med.10.1111/j.1743-6109.2008.0097 [published online ahead of print August 13, 2008]).

Older women's sexual function appears to be particularly sensitive to their health. For instance, having lifetime history of a sexually transmitted infection increased a woman's odds of reporting sexual pain or having lubrication problems. Women with lower urinary tract syndrome were also more likely to report a lack of sexual interest or pleasure, and women who rated their overall health poor also reported a lack of pleasure. For men, those with a lifetime history of sexually transmitted infections were more likely to report unpleasurable sex, and patients treated with genitourinary agents for urinary tract symptoms were more likely to report erectile problems.

Both men and women who reported mental health problems, such as anxiety or depression, had a greater likelihood of sexual problems. However, those who reported they were satisfied in their romantic relationship were less likely to report sexual problems.

“Sexual problems among the elderly are not an inevitable consequence of aging, but instead are responses to the presence of stressors in multiple life domains,” conclude the authors.

Additionally, some medications commonly used in older adults may cause sexual dysfunction. For instance, 30% to 70% of men and women taking antidepressant medications experience sexual dysfunction (Nurnberg HG et al. JAMA. 2008;300[4]:395-404). This adverse event is one of the primary reasons that 70% of patients taking these drugs are nonadherent during the first months of treatment. However, treating medication-associated sexual dysfunction can improve patient outcomes. H. George Nurnberg, MD, of the University of New Mexico School of Medicine in Albuquerque, demonstrated that using sildenafil to treat premenopausal women with antidepressant-associated sexual dysfunction helped to counteract this effect. Previous studies have suggested a similar benefit for men taking sildenafil for sexual dysfunction related to antidepressant use (Nurnberg HG et al. JAMA. 2003;289[1]:56-64).

Opportunities to diagnose and prevent the spread of sexually transmitted infections in this population may also be missed.

There is more lag time between infection and diagnosis in older adults, said Babatunde Olowokure, consultant epidemiologist with the Health Protection Agency in Birmingham, England. Olowokure and colleagues recently published a study of genitourinary medicine clinics in England's West Midlands that found the rate of sexually transmitted infections other than HIV infection doubled among individuals 45 years or older between 1996 and 2003, with 344 such diagnoses in 1996 and 780 in 2003 (Bodley-Tickell AT. Sex Transm Infect. 2008;84[4]:312-317).

Although older adults make up a small proportion of the cases of sexually transmitted diseases and HIV infection in the United States, the number of individuals 50 years or older living with HIV/AIDS has increased from about 65 000 in 2001 to about 116 000 in 2005, based on the Centers for Disease Control and Prevention's (CDC’s) estimates of incidence. Much of this trend can be attributed to the fact that improved treatments are allowing these patients to live longer.

But there is some evidence that the rate of infection may be rising in some US populations as well. For example, there were 341 new diagnoses of HIV/AIDS among individuals 50 years or older in Georgia in 2007 compared with 189 such cases in 1998, according to the Georgia Division of Public Health. In neighboring Florida, individuals 50 years or older made up 11% of new HIV diagnoses in 1998 compared with 17% in 2007, according to the Florida Department of Health. Yet overall, the proportion of US HIV diagnoses that occurred among individuals 50 years or older remained relatively stable, showing only a slight increase between 2001 (13% of HIV/AIDS diagnoses) and 2005 (15%), according to the CDC.

Lindau said that while there is not enough evidence to say there is an epidemic of sexually transmitted infections in older adults, targeted prevention efforts are still important for this population.

Such efforts must take into account factors that may make older adults more vulnerable to infection. Nancy Orel, PhD, associate professor and director of the gerontology program at Bowling Green State University, explained that older adults may have weakened immune systems. In addition, older women may be more vulnerable to infection because more fragile tissue and difficulties with lubrication increase the likelihood of vaginal tears.

Some older adults may have failed to learn important information about preventing HIV infection because they came of age before the emergence of HIV/AIDS and targeted prevention campaigns. “As a group, older adults tend to be the least knowledgeable about HIV,” Orel said.

This lack of knowledge can lead to risky behaviors. Older adults are less likely than younger adults to use condoms (Stall R and Catania J. Arch Intern Med. 1994;154[1]:57-63), in part, because some may view them strictly as contraceptives (Lindau ST et al. J Womens Health [Larchmt]. 2006;15[6]:747-753). Condoms also may be difficult for some individuals to use. Arthritic hands or an incomplete erection may make it difficult to apply a condom; and poor lubrication may make condom use uncomfortable for some women.

High rates of risky behavior among older adults who are already living with HIV/AIDS is a particular concern. One recent survey of 210 sexually active HIV-positive individuals 45 years or older at a US HIV clinic found that 20% reported inconsistent condom use and 33% reported multiple sexual partners (Illa L et al. AIDS Behav. 10.1007/s10461-008-9370-8) (published online in advance of print April 11, 2008). A second survey of 290 HIV-infected adults 50 years or older found that 33% had intercourse without a condom on at least 1 occasion in the past 3 months, and rates of inconsistent condom use were highest among gay or bisexual men (37%) and women (35%) (Lovejoy TI et al. AIDS Behav. 10.1007/s10461-008-9384-2 [published online ahead of print April 4, 2008]).

Although more research is needed on individual interventions, Lindau said physicians can help older patients by providing basic information about sexual functioning in later life, sexually transmitted infections, symptoms that may indicate problems, and how medications may impact sexual function.

“We might prevent the transmission of disease and we might prevent unnecessary worry—or in some cases, shame about the sexual problems patients encounter,” she said.

Information for older patients about issues related to sexuality in later life, including risk of sexually transmitted infections, is available from the National Institute on Aging at http://www.niapublications.org/agepages/sexuality.asp.