Sexuality and Aging

Sexuality is a very important life issue for the elderly, but is often overlooked, according to Cynthia L. Ardito, Psy.D. Ardito frequently speaks on this subject to various health care provider groups in the United States and Canada. Most recently, she presented the topic at the Eastern Massachusetts Alzheimer's Association's Interdisciplinary Professionals Conference, the Massachusetts Association of Older Americans' Conference and the Cambridge Hospital Conference Series.

Ardito, who received her doctorate in clinical psychology from the University of Hartford in 1992, is the director of the Geriatric Group Psychotherapy Program at McLean Hospital in Belmont, Mass., and is an instructor of psychology in Harvard Medical School's psychiatry department. She has also been clinical consultant to McLean's Nursing Home Program and maintains a private practice in Belmont, Mass.

In a telephone interview with Psychiatric Times, Ardito discussed the issue of sexuality and aging.

PT: What do we know about rates of sexuality in later life, and what factors might interfere with remaining sexually active in late life?

Ardito: Our society seems to have the prevailing belief that sexuality is meant primarily for the young. The reality, however, is that sexual feelings, interest, activity and capacities are lifelong. In fact, research has repeatedly shown that the overall best predictor of sexual activity in late life is the level of sexual activity in midlife. We don't have a lot of data about levels of sexual activity in elders, however, and data that are available often don't take into account all elder populations, such as residents in nursing homes, so it is difficult to generalize.

Physically, after age 50, one can expect a general slowing down of sexual responses, but this would not necessitate cessation of all sexual activity. There are, however, some issues that become more prevalent in late life that can negatively impact sexual functioning. One issue is the lack of available partners that significantly limits opportunities for sexual expression, especially for older women. A recent American Association of Retired Persons' [AARP] sexuality survey [Jacoby, 1999] found that 50% of the women surveyed who were between the ages of 60 and 74, and four out of five women age 75 and over, were widowed. This was contrasted with one out of five men age 75 and older who were widowed. An even more poignant fact in this survey was that many of the women without partners also reported being deprived of intimate kisses and hugs. You can see that lack of a partner can significantly limit sexual expression.

Another issue is that, as people age, there is a greater incidence of illness and progression of chronic diseases that can negatively impact sexual functioning. Many of the pharmacological treatments for these medical problems carry side effects that can also have a negative impact. This is very significant when we keep in mind that, as a group, the elderly are the largest consumers of prescription and nonprescription medications.

Some of the medical problems that might have a large impact on sexuality are diabetes, hypothyroidism, neuropathy, cardiovascular disease, urinary tract infections, prostate cancer, incontinence, arthritis, depression, dementia, chronic alcoholism and heavy smoking.

Medications known to have side effects that may contribute to erectile dysfunction include some antihypertensives, antidepressants, diuretics, steroids, anticonvulsants, -blockers, estrogens, opiates and others. We have less research on the impact of medications on women's sexual functioning, but studies have shown that antidepressants can inhibit orgasm, and some antihypertensives, anticholinergics and antihistamines have been found to negatively impact sexual functioning in women.

There are also a number of psychosocial issues that can impact sexual activity in later years, including changes in roles and finances after retirement; anxiety and depression related to age-associated losses and transitions; and personal, religious and moral beliefs regarding one's sexuality in late life.

PT: What can health care providers do to combat some of these problems?

Ardito: To put it bluntly, we need to start talking about sex. Our patients come to us with a wide variety of issues, and we need to feel comfortable at least broaching the topic of sexuality. Many elders have reported that when they were provided with accurate information they were able to incorporate new sexual knowledge and discard long-standing fears and misconceptions that had significantly limited their sexual expression for much of their lives.

Obviously, as health care providers, we have time limitations. But don't assume that patients are not sexually active just because they don't have a partner or are very old. For example, we need to make sure an 80-year-old is receiving the same information a 30-year-old would receive regarding the possible sexual side effects of antidepressant use. If we are not comfortable talking about these issues, our patients aren't really going to feel comfortable asking for help and information.

Regarding specific treatments for sexual dysfunction in older adults, Viagra [sildenafil] is perhaps the most talked about treatment for erectile dysfunction these days, but it is certainly not the only treatment available. There are other medications currently being used for the treatment of sexual dysfunction in both men and women, and research regarding future pharmacological treatments is ongoing.

It is also important to keep in mind that there are many behavioral strategies that can be used to adjust to age- or illness-related changes in sexual functioning. Patients can be directed to the appropriate sources of this information and can be assisted in communicating with their partners, which obviously makes a big difference in terms of managing any type of sexual dysfunction.

With regard to medications, estrogen has been used to facilitate desire and arousal in women and testosterone is being used in women to treat more global sexual dysfunction. Alprostadil [Caverject, Muse] has been used successfully for erectile dysfunction in men, and it does have some vasodilation effects for both men and women. Some amphetamines, such as methylphenidate [Ritalin], have been used to increase sexual responsitivity in women. Medications that stimulate dopamine, such as apomorphine [Uprima], are being researched for treatment of sexual dysfunction in both men and women. Research has been done on a new vasodilator called Vasomax [phentolamine] by Zonagen. It is scheduled to be available early in 2000. Researchers at Palatin Technologies Inc. are scheduled to begin controlled studies on a hormone called PT-14, which would act directly upon the central nervous system and reportedly creates an erection whether or not a man is sexually aroused.

Americans are also looking into some of the alternative medicines. No controlled studies have yet been published, and these supplements are not approved by the U.S. Food and Drug Administration and can have negative side effects, but Ginkgo biloba, ginseng [Panax ginseng] and ma huang [Ephedra sinica] are some herbal remedies that are purported to have positive sexual effects.

In terms of behavioral strategies that patients can use, health care providers don't have to be experts in human sexuality to discuss options. Patients should be reminded that basic changes in diet and exercise and cessation of alcohol use or smoking have a positive impact on libido and sexual functioning. For men, testosterone levels are highest in the morning, so scheduling sexual activity in the morning can be helpful. Testosterone levels can also rise in anticipation of sexual activity and after engaging in it, which supports the idea that being more sexually active will help one remain more sexually active. If an elder is suffering from arthritis, a hot bath prior to sex can loosen joints and increase comfort for an hour or so. Prolonged foreplay can enhance sexual arousal in both men and women. Stroke victims can work with a physical therapist to find a footboard or use other strategies to increase mobility. Making changes in sexual positions can also help partners adapt to various disabilities.

Vaginal dryness is very common and can be remedied by allowing more time for the woman to get aroused and by using lubricants that are available over the counter. Kegel exercises can be utilized to strengthen the muscles of the vaginal floor, which can enhance sensation and orgasm. Again, communication is a huge key to decreasing a sense of failure, anxiety or pressure. It is important to allow elders to talk about these issues rather than just ceasing sexual activity. Health care providers can help elders maintain open lines, or reopen long-neglected pathways of communication and self-expression.

PT: What about HIV and AIDS in elderly populations?

Ardito: AIDS is often regarded as a young person's disease. Since the beginning of the epidemic in the United States in the early 1980s, however, 10% of all AIDS cases are diagnosed in Americans 50 years and older [AARP, 1998].

This is a complicated issue for the elderly because HIV and AIDS are often misdiagnosed in this population, as symptoms often mimic other illnesses. Elders are also at a greater risk than younger people of conversion of HIV into AIDS, and conversion is more rapid. Also, many of the present treatment options for HIV and AIDS are not viable for elders who might have multiple medical conditions and be taking multiple medications. Elders are not getting sexual education and AIDS prevention information. They are less likely to use condoms, less likely to get AIDS tests and less likely to be asked about this issue. Health care professionals can attempt to address this by trying to increase AIDS education and doing risk assessments in this population. Knowing where to direct elders who are in need of these selective resources is also important. Often, elders don't know where to go when they do find out they have the disease and may receive less support than other age groups.

PT: What about sexuality in nursing homes?

Ardito: This is also an often-neglected issue. The bottom line is you don't lose your legal right to sexual expression when you sign into a nursing home. It often gets more complicated, however, because it becomes more of a public issue with staff, and often family members, involved. It gets even more complicated when looking at nursing home residents with dementia.

In addition to privacy issues, there are issues of problematic sexual behavior as well as appropriate sexual behavior. So it is again important for health care providers to assist nursing homes in addressing the sexual needs of residents in a sensitive, safe and respectful manner that promotes high quality of life rather than taking more rights away from these residents.

PT: What does the future hold for the field of late-life sexuality?

Ardito: We are just beginning to explore and understand this area. There is a great deal of research that needs to be done about the present cohort of elders; there is going to be even more to learn as younger generations age, bringing with them different values, experiences and knowledge regarding sexuality. It is an ever-changing field. Definitely, we need to talk more about it, ask more about it and do more research in the area.

For many older adults, sexual expression is not just some frivolous pleasure, but it is integral to attaining or maintaining a high quality of life. We as health care providers can focus on promoting this high quality of living.

References:

References

AARP (1998), HIV/AIDS and older adults. Available at:

http://www.aarp.org/press/1998/nr100198.html

. Accessed Nov. 23, 1999.

Jacoby S (1999), Great sex: What's age got to do with it? Modern Maturity Sept./Oct. Available at:

http://www.aarp.org/mmaturity/sept_oct99/greatsex.html

. Accessed Nov. 23.

Barlik B, Kaplan P, Kaminetsky J et al. (1999), Medication with the potential to enhance sexual responsivity in women. Psychiatric Annals 29(1):46-52.

McCartney JR, Izeman H, Rogers D, Cohen N (1987), Sexuality and the institutionalized elderly. J Am Geriatr Soc 35(4):331-333.

Stall R, Catania J (1994), AIDS risk behaviors among late middle-aged and elderly Americans. The National AIDS Behavioral Surveys. Arch Intern Med