Chapter 14. Sexuality and Aging
© American Psychiatric Publishing
People are living longer and healthier lives, and many expect sexuality to continue to play an important role. As a result, sexual issues and disorders are an important part of assessment and treatment by the geriatric psychiatrist, in both outpatient and long-term-care settings. The idea of sexuality in late life, once commonly regarded with denial, humor, or even disgust, too often led clinicians to view sexual dysfunction as a normal and untreatable part of aging. Such distorted attitudes have changed widely, however, starting with the sexual and feminist revolutions in the 1960s and 1970s and buoyed by the widespread use of hormone replacement therapy and then the advent of oral erectogenic agents for erectile dysfunction. This widespread openness toward late-life sexuality coupled with reliable treatments for sexual dysfunction has made sexuality a more common and comfortable topic of conversation among aged individuals and their clinicians, and can now ensure the persistence of enjoyable sexual function in later years. In addition, the destigmatization of sexual dysfunction has no doubt encouraged many older couples to seek treatment who otherwise might have suffered in silence and shame.
Sexual Behaviors in Late Life
Several major studies over the past 25 years have shown that a majority of middle-aged and older individuals continue to be sexually active, although with modest decreases in activity, determined in part by gender and the availability of partners. These studies have indicated that older men are more sexually active than older women and that individuals with steady partners are more active than single individuals. In general, sexual interest and activity in late life depend on the previous level of sexual activity; the availability, health, and sexual interest of the partner; and the individual’s overall physical health (Lindau et al. 2007; Schick et al. 2010). Physical health appears to be the most important factor for older men, whereas the quality of the relationship is most influential for older women.
Early surveys of sexuality in late life by Marsiglio and Donnelly (1991) and the National Council on the Aging (1998) both found that a majority of individuals over age 60 remained sexually active (defined as having sexual intercourse at least once a month), with men being more sexually active and overall rates generally declining with increased age. These findings have been supported by a series of studies of late-life sexuality conducted by AARP (which changed its name from the American Association of Retired Persons in 1999). In the original 1999 mail survey, researchers gathered responses from 1,384 men and women ages 45 years and older (Jacoby 1999). The survey found that three-quarters of both men and women in the sample remained sexually active. Eighty-four percent of men and 78% of women ages 45–59 years had steady sexual partners, compared with 58% of men and 21% of women older than age 75. In terms of frequency, 50% of individuals ages 45–59 years reported having sex at least once a week, compared with 30% of men and 24% of women ages 60–74 years. Of the respondents, the majority of men without partners said they masturbated, whereas more than 77% of women did not. The study also examined attitudes toward specific aspects of sexuality; 60% of men and 35% of women said that sexual activity was important to their overall quality of life. Two-thirds of all respondents were extremely or somewhat satisfied with sex. Attitudes toward partners were generally favorable, with a majority of both genders describing their partners with terms that included “best friend,” “kind and gentle,” and “physically attractive.” The study also found several generational differences in attitudes toward sex. Individuals older than age 60 were less likely than younger respondents to approve of oral sex, masturbation, and sex between unmarried partners.
A 2004 update of the AARP late-life sexuality study surveyed 2,930 men and women in the United States ages 45 years and older, and included respondents with African American, Asian, and Hispanic ethnicity (AARP 2005). Of this group, approximately two-thirds were married or living with a partner, and 5% identified themselves as gay or lesbian. Attitudes toward sexuality were remarkably similar to those seen in the 1999 survey, with only a few new findings. As before, the vast majority of individuals had positive attitudes toward sex, and those with partners described themselves as more satisfied, optimistic, and tolerant than those without partners. African Americans and Hispanics were more likely to be extremely satisfied with their partners. Those who engaged in physical exercise on a regular basis had greater degrees of sexual satisfaction. An increasing number of individuals were seeking information on sex from the Internet and from health care providers. Compared with the 1999 survey, the 2004 survey found less opposition to sex between unmarried partners.
The 2004 AARP survey found no major changes in sexual behaviors, with 86% of respondents continuing to be sexually active. Men were more active than women, and rates of sexual activity declined with age. The percentage of men seeking erectogenic medications doubled from 10% to 22%, with 68% of these respondents saying that the treatment helped. The number of women undergoing hormone replacement therapy dropped by 50%, no doubt related to warnings about increased cancer risk. More individuals reported engaging in masturbation and oral sex in 2004 than in 1999. Sixty percent of men and 50% of women reported engaging in masturbation at least once in the 6 months prior to the survey.
AARP conducted another survey in 2009 using a probability sample of 1,670 individuals ages 45 years and older, which included 630 Hispanic respondents (Fisher 2010). In contrast to previous surveys, the overall percentage of individuals having sexual intercourse at least once a week dropped about 10 points to 41% of those with a steady partner (and 28% overall), and there were similar drops in levels of sexual satisfaction. Approximately 50% of men and 26% of women ages 45–49 years reported having sexual intercourse at least once a week, which dropped to 15% of men and 5% of women ages 70 years and older. Levels of both sexual activity and satisfaction were higher among individuals who were single than among those who were married. Although all of these findings suggest important changes from previous surveys, it is important to keep in mind that the methodology of the 2009 survey was different, using telephone versus mail surveys.
The AARP study findings are consistent with those of several other surveys. Lindau et al. (2007) interviewed a probability sample of 3,005 adults ages 57–85 in the United States and found that 73% of those ages 57–64 years were sexually active, declining to 53% of those ages 65–74 and 26% of those 75 and older. Rates of having sex at least two to three times per month fell from 67.5% of men and 62.6% of women in the youngest cohort, to 65.4% of both men and women in the middle cohort, and to 54.2% of men and 54.1% of women in the oldest cohort. Overall, men were more sexually active than women across all age groups. Older individuals with poorer health rankings were less sexually active and more prone to sexual dysfunction. A large cross-national study of 27,000 older individuals in 29 countries found that men had increased levels of sexual satisfaction, regardless of the country, and that sexual satisfaction decreased with increasing numbers of partners (Laumann et al. 2006).
Aging Gay and Lesbian Individuals
There are approximately 1–3 million gay and lesbian individuals over age 60 in the United States, and this number is expected to double in the next 30 years. The 2009 AARP survey found that 8% of male and 2% of female respondents reported having same-sex relationships; 3% of men described themselves as gay, less than 0.5% of women reported being lesbian, and 1% of respondents described themselves as bisexual (Fisher 2010). A small but growing literature indicates that older gay and lesbian individuals continue to be sexuality active and to feel high levels of satisfaction with both their lifestyle and their sex lives (Adelman 1990). In one study of 100 gay men ages 40–77 years, 80% remained sexually active, with 34% reporting having sex more than once a week and 69% reporting the same amount of sexual enjoyment as when they were younger (Pope and Schulz 1990). Kimmel (1977) earlier reported similar findings and suggested that gay men might have a number of age-associated advantages, including being less dependent on family and children and having large networks of supportive friends.
Sexuality in Long-Term-Care Settings
Sexuality among residents in long-term-care settings is stigmatized not only because the residents are elderly but also because they are no longer living independently and often have multiple medical and psychiatric problems, including cognitive impairment. As a result, both residents and staff tend to view sexuality in a negative manner. In one study, for example, even though the majority of long-term-care staff acknowledged the sexual needs of residents, most did not think it was necessary for these individuals to be sexually active (Mroczek et al. 2013; Saretsky 1987). Residents often feel sexually unattractive and are pessimistic about whether sex would even be possible or enjoyable (Kaas 1978; Wasow and Loeb 1979). Not surprisingly, the rate of sexual activity is low in most nursing homes (Hajjar and Kamel 2004a; Mulligan and Palguta 1991). For many residents, however, the desire for sexual relationships still exists. In a 1982 study involving 250 nursing home residents, White (1982) found that 91% had not been sexually active in the last month and 17% wanted to be sexually active but lacked privacy or a partner. Other common barriers to sexual activity among long-term-care residents include loss of interest, chronic illness, sexual dysfunction, and negative attitudes of staff (Hajjar and Kamel 2004a; Richardson and Lazur 1995; Wasow and Loeb 1979).
When one or both members of a couple are living in a long-term-care facility, staff must be aware of residents’ rights to sexual expression. Mental health consultants can help remove barriers to sexual activity in long-term-care settings in several ways. A key to accomplishing this goal is educating staff about sexuality in late life so that stereotypes are dispelled. Such an education provides staff with an understanding of residents’ rights to sexual expression and the role of sexuality in helping residents meet needs for intimacy and physical contact (Roach 2004; Spector et al. 1996). Also, residents should be educated about sexuality in late life and about their sexual rights. One way to facilitate these educational goals for residents and staff in long-term-care settings is to develop and promote a policy on sexuality.
To carry out such a policy, clinical staff in long-term-care facilities should ensure that a sexual history is obtained during intake and routine nursing, medical, and mental health evaluations. These evaluations can also be used to assess residents’ concerns and capacities with respect to sexual function and relationships. Long-term-care facilities must ensure adequate privacy for couples wishing to be intimate and must facilitate conjugal or home visits. To this end, facilities might provide private rooms for married couples or individuals with other partners, when feasible. Privacy can be increased with “Do Not Disturb” signs, locks on doors, and reminders to staff and residents to knock before entering a resident’s room (Spector et al. 1996). Finally, facilities can provide beauty services such as hair styling and manicures (Richardson and Lazur 1995).
The Sexual Response Cycle and Aging
The effects of aging on sexual function must be viewed against the backdrop of normal adult sexual response. A four-stage model of the normal sexual response cycle was developed by sex researchers William Masters and Virginia Johnson (1966) from their pioneering work in human sexuality. The four-stage cycle illustrates the physiological changes that take place in the body during sexual activity. These four stages are excitement or arousal, plateau, orgasm, and resolution. Kaplan (1974) and others added a fifth stage, desire, to account for a psychological and physiological component of sexuality that underlies sexual response (Snarch 1991; Zilbergeld and Ellison 1980). In this later model, sexual response is not a linear process but rather a waxing and waning pattern of sexual arousal that may culminate in orgasm, depending on a host of factors. All of these factors can be influenced by age-related changes in sexual function.
The first stage of the five-stage model, desire, involves physical and psychological urges to seek out and respond to sexual interaction. This drive is centered in the limbic system of the brain, particularly in the hypothalamus, and is stimulated in both sexes by testosterone. Desire is intimately linked to the physiological process of sexual excitement or arousal (the second stage); it is difficult for one to exist without the other. In both men and women, sexual arousal can be triggered by thoughts and fantasies or by direct physical stimulation. Autonomic nervous stimulation leads to predictable physiological responses, including increased muscle tone, increases in heart and respiratory rates, and increased blood flow to the genitals (vasocongestion). In men, these responses result in penile erection, whereas in women, they result in vaginal lubrication and swelling of breast and genital tissues, especially the clitoris. The relatively brief plateau stage is characterized by a sense of impending orgasm and is followed by orgasm and then a refractory period of relaxation called resolution. In both sexes, orgasm is characterized by euphoria associated with rhythmic contractions of genital muscles. In men, orgasm is brief and is accompanied by ejaculation. In women, orgasm tends to last longer and there may be multiple successive occurrences.
Normal aging produces several changes in the sexual response cycle (Table 14–1). In women, the most significant changes occur during menopause, a 2- to 10-year period that usually ends in the early 50s. The decline and eventual cessation of ovarian estrogen production during menopause leads to important changes in sexual function, including atrophy of urogenital tissue; a decrease in vaginal size; and diminished vaginal lubrication, vasocongestion, and erotic sensitivity of nipple, clitoral, and vulvar tissue (Wilson 2003). As a result, sexual desire may decrease, sexual arousal may require more time, sexual intercourse may be more uncomfortable because of reduced lubrication of vaginal and clitoral tissue, and orgasms may be felt as less intense (Dennerstein et al. 2008). Up to 85% of menopausal women also experience symptoms such as hot flashes, headaches and neck aches, mood changes, and excess fatigue. During menopause, women also experience decreases in testosterone production that may lead to diminished sensitivity of erogenous tissue and reduced libido (Morley 2003; Nappi et al. 2006).
The Sexual Response Cycle and Aging Normal age-related changes in sexual function
Men
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Testosterone production modestly decreases, with unpredictable effect on sexual function.
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Sperm count changes minimally, but amount of functional sperm and rate of conception decrease.
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There are no predictable changes in sexual desire (libido).
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Increased tactile stimulation is needed for sexual arousal.
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Erections take longer to achieve and are more difficult to sustain.
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Penile rigidity decreases because of decreases in blood flow and smooth muscle relaxation.
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Sensation of urgency during plateau stage is diminished.
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Ejaculation is less forceful, with decreased ejaculate volume.
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Refractory period increases by hours to days.
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Women
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During menopause, estrogen production decreases and eventually stops.
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Sexual desire (libido) may decrease due in part to decreased testosterone levels.
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Blood supply to pelvic region is reduced.
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Vagina shortens and narrows. Vaginal mucosa is thinner and less lubricated.
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During arousal, vaginal lubrication and swelling occur more slowly and are decreased.
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Sexual arousal may take longer and may require increased stimulation.
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During orgasm, strength and amount of vaginal contractions decrease.
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Source. Agronin and Westheimer 2011; Westheimer and Lopater 2002.
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In most women, hormone replacement therapy largely reverses these menopause-associated changes in sexual function. Estrogen is often prescribed with the synthetic progesterone, called progestin, to replicate previous hormone levels. It can be administered orally or via a slow-release transdermal patch (Alexander et al. 2004). In addition, estrogen cream can be applied directly to genital tissues to relieve irritation and enhance lubrication (Minkin et al. 2014; Suckling et al. 2006). Unfortunately, overall research findings have indicated a small but potentially unacceptable risk of stroke and breast cancer associated with long-term oral hormone replacement therapy, which therefore is not recommended (Lacey et al. 2002; Marjoribanks et al. 2012; Nelson et al. 2012; Rossouw et al. 2002).
Compared with women, the sexual changes in aging men occur more gradually with a less predictable time frame (Morley 2003; Westheimer and Lopater 2002). As men age, desire may involve less anticipatory physical arousal, and sexual arousal and orgasm may take longer to achieve. Older men require more physical stimulation to achieve erections, which tend to be less frequent, less durable, and less reliable. The volume of ejaculate during orgasm is decreased. In older men, the resolution or refractory stage is much longer, lasting hours to days instead of minutes to hours as in younger men. Testosterone levels in men decline 35% on average by age 80 years, although some men have more significant declines, with levels dropping below 200 ng/dL, the level at which they are diagnosed with hypogonadism (Morley 2003). Some researchers have suggested the existence of a male menopause or andropause resulting from declining testosterone levels and involving a symptom complex that includes decreased libido and sexual function; diminished bone and muscle mass, muscle power, and body hair; and decreased lean body mass (Haider et al. 2014; Heaton and Morales 2001; Morley and Perry 2003; Pines 2011). Research has suggested, however, that these changes are quite variable, and that testosterone replacement therapy has inconsistent results (Harman 2005).
In both sexes, the effects of physiological changes in sexual function are mediated by a number of psychosocial factors. The more an individual knows about what constitutes normal age-associated changes in sexual function, the easier it may be for him or her to accept these changes. For example, a man who does not understand the normal changes in erectile function may misinterpret them and believe that he has a sexual problem. Similarly, a woman may misinterpret vaginal dryness as an indication that she does not want to have sex. Such overreactions to normal changes can lead an individual to engage in less frequent or more limited sexual activity.
In addition, some older individuals may accept ageist stereotypes about sexuality and view their behaviors as inappropriate or potentially harmful, despite the individuals’ relatively normal sexual desire and capacity. Other individuals may lose self-confidence and feel less sexy, especially as they struggle to cope with age-associated changes in physical appearance, strength, and endurance. Such attitudinal barriers may be more damaging to sexuality than actual physiological changes.
The quality of an individual’s relationship with a partner is also influential. Couples often have to adapt sexual technique and spend more time on foreplay to preserve previous levels of sexual function and enjoyment. Partners who are unable to work together may experience difficulty with sex and perhaps even sexual dysfunction. On the other hand, aging can bring new possibilities for sexuality in later life. Partners may have more time to spend with each other once children have left home or during retirement. For postmenopausal women, sex may be associated with a reduced level of anxiety because of the impossibility of pregnancy.
Sexually Transmitted Diseases
None of the published surveys about late-life sexuality asked respondents about sexually transmitted diseases (STDs), even though older people are certainly at risk for contracting them. According to surveillance data from the Centers for Disease Control and Prevention (2012), rates of STDs including chlamydia, gonorrhea, and syphilis in individuals ages 65 years and older were the lowest of any group and had not changed appreciably in the previous 5 years. In a study from Washington State, the most common STDs in older individuals were nongonococcal urethritis in men and genital herpes in women—representing 1.3% of all reported cases of STDs (Xu et al. 2001). With respect to HIV and AIDS, the largest increase in individuals living with HIV infection from 2008 to 2010 was among individuals older than 65 years, with a rate at the end of 2010 of 85.7 per 100,000 persons in the United States. Although rates of new infections among the elderly have been decreasing, rates of stage 3 AIDS and death have increased (Centers for Disease Control and Prevention 2011). It should be noted that not all of these cases are due to sexual transmission.
Despite these low prevalence rates for STDs, older individuals remain at risk because they continue to be sexually active. Adding to this risk is the fact that many older people never received the sex education provided to today’s younger population. Thus, they may neglect safe-sex practices due to lack of knowledge, the absence of pregnancy risk, and a false sense of safety from knowing that STDs are more prevalent in younger people. One survey of a representative sample of 1,670 individuals 45 years and older found that less than 20% of men and women who were single and dating reported using a condom or any other form of protection on a regular basis during sexual intercourse (AARP 2010). Given these lapses in safe-sex measures, education about sexuality, STDs, and safe-sex practices remains critical throughout the entire adult life cycle.
Sexual Dysfunction in Late Life
Although the majority of older individuals continue to engage in sexual activity, the prevalence of sexual dysfunction does increase with age (Lindau et al. 2007; Mulligan et al. 2003). The DSM-5 (American Psychiatric Association 2013) classification of sexual disorders is provided in Table 14–2. Erectile disorder (ED) is the most common form of sexual dysfunction in older men, affecting 20%–40% of men in their 60s and 50%–70% of men in their 70s and 80s (Feldman et al. 1994; Laumann and Waite 2008; Lewis et al. 2004). In older women, the most common forms of sexual dysfunction are DSM-IV-TR (American Psychiatric Association 2000) hypoactive sexual desire, female orgasmic disorder, and dyspareunia (Bitzer et al. 2008; Lindau et al. 2007). The percentage of women with low sexual desire increases from 10% of women younger than age 50 to nearly 50% of women in their late 60s and 70s (Lewis et al. 2004). One study found that 44%–49% of women ages 57–85 years reported low desire, 35%–44% had difficulty with lubrication, and 34%–38% had anorgasmia (Lindau et al. 2007). In the same study, 31%–44% of men reported ED, and 14% were taking medications for it.
Sexual Dysfunction in Late Life DSM-5 classification of sexual dysfunctions
The symptoms of each of these sexual disorders occur on almost all or all occasions of sexual activity:
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Female sexual interest/arousal disorder: Absent or reduced sexual interest, thoughts or fantasies, initiated behaviors, excitement or pleasure, or genital or nongenital sensations during sexual activity or in response to sexual stimulation
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Male hypoactive sexual desire disorder: Persistent or recurrent deficiency in or absence of sexual thoughts, fantasies, or desire
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Erectile disorder: Marked difficulty in attaining an erection during sexual activity, or marked difficulty in maintaining an erection until the completion of sexual activity, or marked decrease in erectile rigidity
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Delayed ejaculation: Marked delay in ejaculation or marked infrequency or absence of ejaculation
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Female orgasmic disorder: Marked delay in, infrequency of, or absence of orgasm, or markedly reduced intensity of orgasmic sensations
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Premature (early) ejaculation: Persistent or recurrent pattern of ejaculation during partnered sexual activity within approximately 1 minute following vaginal penetration
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Substance/medication-induced sexual dysfunction: Significant disturbance in sexual function during substance intoxication or withdrawal or after exposure to a medication
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Genito-pelvic pain/penetration disorder: Persistent or recurrent difficulties during intercourse with vaginal penetration, pelvic pain, fear or anxiety about pain, or tensing and tightening of pelvic floor muscles
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Unfortunately, physicians often fail to ask older patients about sexual function, perhaps due to their discomfort with the topic or acceptance of ageist stereotypes. As a result, many older individuals endure treatable forms of sexual dysfunction and are either too ashamed to inquire about treatment or are ignorant or pessimistic about treatment. The geriatric psychiatrist can play a vital role in providing support, education, and treatment to such individuals.
Although medical and psychiatric problems and medication effects are usually the main causes of sexual dysfunction in late life, numerous psychological factors must be considered, including performance anxiety, the presence of another sexual disorder in one or both partners, fears of self-injury or death due to medical conditions (e.g., a history of myocardial infarction, shortness of breath), sensitivity to loss of personal appearance or control of bodily functions (e.g., incontinence), relationship problems, and life stress. The first occurrence of psychogenic sexual dysfunction often follows a stressful event such as the loss of a loved one, a divorce, a financial or occupational strain, or a major health scare. Such major stresses may break sexual patterns and lead to uncertainty about how to resume sexual activity. As noted, the availability of partners is an acute issue for women, who outnumber men by more than two to one by age 85 years.
Medical and psychiatric disorders that are the most common causes of sexual dysfunction in geriatric patients are listed in Table 14–3. In both sexes, major risk factors for sexual dysfunction include diabetes mellitus, peripheral vascular disease, cancer, pulmonary disease, depression, stroke, dementia, Parkinson’s disease, and substance abuse. These and other medical disorders exert both primary and secondary effects on sexual function. Examples of primary effects include impaired sexual arousal due to diabetic neuropathy and impaired genital vasocongestion due to peripheral vascular disease. Secondary effects such as fatigue, pain, and physical disability due to medical illness can make individuals feel less sexy and less confident in their sexual ability, which in turn can lead to hypoactive desire. Medications can also cause sexual dysfunction and can affect both men and women at any point in the sexual response cycle (Crenshaw and Goldberg 1996; Goodwin and Agronin 1997; Ludwig and Phillips 2014; Thomas 2003). The most common problematic medications include antihypertensives such as β-blockers and diuretics, antiandrogens, and many psychotropic medications (Nicolai et al. 2014; Segraves and Balon 2014; Zajecka 2003). Some of the medications most commonly associated with sexual dysfunction in late life are listed in Table 14–4.
Sexual Dysfunction in Late Life Medical and psychiatric conditions commonly associated with sexual dysfunction in late life
Anxiety disorders (generalized anxiety disorder, panic disorder); obsessive-compulsive disorder
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Arthritis and other degenerative joint diseases
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Atherosclerosis (peripheral vascular disease, stroke)
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Cancer (especially urologic and genital cancers and their treatments)
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Cardiac disease (coronary artery disease, congestive heart failure, myocardial infarction)
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Chronic obstructive pulmonary disease
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Chronic organ failure (renal, hepatic)
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Neurocognitive disorder (e.g., due to Alzheimer’s disease or cerebrovascular disease)
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Diabetes mellitus
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Major depressive disorder and other mood disorders
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Multiple sclerosis
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Parkinson’s disease
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Prostate disease and prostate surgery
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Schizophrenia and other chronic psychotic disorders
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Substance abuse
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Sexual Dysfunction in Late Life Medications associated with sexual dysfunction in late life
α-Adrenergic blockers (prazosin, phentolamine)
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Antiandrogens (leuprolide, ketoconazole)
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Antidepressants (MAOIs, TCAs, SSRIs, venlafaxine)
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Antihistamines
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Antihypertensives (thiazide diuretics, β-blockers, ACE inhibitors, clonidine, spironolactone, calcium-channel blockers, reserpine)
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Antipsychotics (conventional and atypical)
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Benzodiazepines
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Cancer chemotherapeutic agents
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Cardiac medications (e.g., digoxin, amiodarone)
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Corticosteroids
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Disopyramide
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l-Dopa
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Histamine subtype 2 (H2) receptor blockers
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Mood stabilizers (lithium, valproic acid, carbamazepine)
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Note. ACE = angiotensin-converting enzyme; MAOI = monoamine oxidase inhibitor; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant.
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Sexual dysfunction in late life is often comorbid with other psychiatric disorders. Symptoms range from transient dysfunction, present only during episodes of illness, to full-blown sexual disorders independent of the primary psychiatric disorder. Major depression often features loss of libido but may also be associated with inhibited arousal and ED. Symptomatic anxiety as well as anxiety and panic disorders are frequently associated with sexual dysfunction—in particular, sexual phobias and sexual aversion (Kaplan 1987). Unfortunately, many of the antidepressants used to treat mood or anxiety disorders can cause or exacerbate sexual dysfunction (see Table 14–4). ED, delayed or inhibited orgasm, and/or a decrease in desire is experienced by 10%–60% of men taking serotonin selective reuptake inhibitors (SSRIs), venlafaxine, or tricyclic antidepressants (TCAs) (Montejo et al. 2001; Segraves 1998). Lower rates of sexual dysfunction have been associated with the antidepressants mirtazapine (25%), bupropion (5%–15%) and nefazodone (8%) (Kavoussi et al. 1997; Montejo et al. 2001; Reichenpfader et al. 2014).
Individuals with schizophrenia and other psychotic disorders often have sexual problems. Psychotic individuals with negative symptoms—such as social withdrawal or discomfort in the presence of others, apathy, and blunted affect—may have relatively little interest in sexual relationships. Psychotic patients with positive symptoms—such as delusions, hallucinations, and bizarre thought patterns—may have difficulty relating to others and interacting in sexually comfortable or appropriate ways. During periods of symptom remission, however, sexual relationships can be more appropriate. All antipsychotic medications can cause sexual dysfunction, usually in proportion to the dose; higher rates of dysfunction occur with prolactin-raising agents such as risperidone, haloperidol, olanzapine, and clozapine (40%–60%) than with prolactin-sparing agents such as quetiapine, aripiprazole, and ziprasidone (16%–27%) (Baggaley 2008; Serretti and Chiesa 2011). Like antidepressant and anxiolytic medications, antipsychotics can decrease libido, interfere with sexual arousal, and inhibit erections, ejaculation, and orgasm (Baggaley 2008).
Assessment
The assessment of sexual dysfunction in late life involves identifying the specific problem and then obtaining a comprehensive medical, psychiatric, and sexual history to determine potential causes. A comprehensive sexual history involves asking an individual about prior sexual experiences, current sexual functioning, and attitudes toward sexuality and toward any current partner. With older couples, interviewers must be able to identify relevant age-appropriate issues (Agronin 2014; Agronin and Westheimer 2011). It is important to balance the need to gather sexual history with the responsibility to be sensitive to the fact that sexual data may be some of the most personal information that a patient will ever divulge. Finally, accurate assessment of sexual dysfunction in late life depends to a large degree on a comfortable and productive doctor-patient relationship, one in which the patient and his or her partner feel secure enough to disclose adequate history and the physician asks the right questions and has sufficient testing performed. Partner involvement is crucial to a successful outcome.
The medical workup for sexual dysfunction may involve a physical examination, laboratory testing, and specialized diagnostic testing. The focus of the physical examination is on genital and urological anatomy and function, including underlying vascular and neurological function. Laboratory testing typically involves examination of routine blood chemistry (e.g., blood count, electrolyte levels, glucose levels, lipid profile), testosterone and prolactin levels, thyroid function, and, in men, prostate-specific antigen levels. Specialized diagnostic tests for ED may include nocturnal penile tumescence and rigidity testing (to determine whether natural erections occur during sleep) and penile duplex ultrasonography (to assess blood flow in the penis). This workup is typically conducted by a urologist.
Treatment
Preservation and enhancement of sexual activity in geriatric patients require recognition of and sensitivity to the fact that many of these individuals want and intend to continue having sex, despite changes in physical and sexual function. Once an evaluation is complete, both partners should be educated about normal and dysfunctional sexuality (Bitzer et al. 2008). This information helps to reassure the affected individual that he or she is not the only person with the particular problem, that the problem has specific causes, and that it can be treated. In addition, clinicians can help patients recognize sexuality as a form of physical and psychological intimacy and not solely as sexual intercourse. This discussion will build trust between the patient and the clinician, and will help the patient feel comfortable about seeking follow-up and being open about emotional reactions to the problem. Many treatments fail at this point, not because the treatments cannot work but because the patient and the clinician never establish a solid working relationship. Treatment can also fail when one partner refuses to cooperate with treatment or when problems within the couple’s entire relationship become insurmountable.
Unique challenges are faced by couples in which one or both partners have a chronic medical illness or disability. These couples often need to shift their focus from intercourse to foreplay and to adapt sexual practices to account for physical limitations such as fatigue, loss of muscle strength, and pain (Agronin and Westheimer 2011; Morley and Tariq 2003; Schover and Jensen 1988). Education is key. Organizations such as the American Cancer Society, the United Ostomy Associations of America, National Jewish Health (on respiratory disorders), and others have developed helpful Internet guides to maintaining sexual function despite specific medical illnesses. Physicians should work to maximize both rehabilitative and palliative treatments—for example, making use of analgesics for pain, inhalers for shortness of breath, or physical therapy for joint immobility and muscle weakness. In addition, appropriate treatment of depression, anxiety, or psychosis can often lead to significant improvement in sexual function, assuming that the medications used to treat these disorders do not themselves cause problems. Some ways in which an older couple can enhance sexual function and cope with disability are outlined in Table 14–5.
Treatment Ten ways to enhance sexual function in late life
1. Cultivate a positive attitude toward sexuality in later life.
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2. Maintain optimal health and fitness. Avoid use of tobacco and excessive use of alcohol.
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3. Maintain open and honest communication with your partner about how your sexual responsiveness has changed over time.
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4. Focus on foreplay as much as on intercourse. Be open-minded about adapting sexual practices to your needs.
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5. Maximize treatment of medical problems or disabilities that are interfering with sexual function. Consult a physician about any concerns regarding excess exertion during sex. To achieve adequate stamina, use appropriate exercise to build up strength and self-confidence.
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6. Before sex, maximize treatment of symptoms that affect sex. For pain, consider taking a warm shower or bath, having a relaxing massage, or taking analgesics before sex. For shortness of breath, adapt sexual activity to minimize exertion and use prescribed inhalers ahead of time. Choose times of day for sex when pain is at a minimum.
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7. If you are a woman, consider the use of estrogen cream, which can relieve vaginal dryness and improve vasocongestion in peri- or postmenopausal women. Tender genital or breast tissue may require more gentle stimulation, sometimes along with the use of an external lubricant.
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8. Identify problematic medications and investigate alternative agents or strategies.
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9. Avoid unrealistic expectations that sex must be the same as when you were younger.
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10. Explore sexual positions that decrease exertion or account for equipment such as oxygen tanks or ostomy bags. Suggested positions for intercourse include lying side by side or sitting face-to-face.
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Source. Agronin and Westheimer 2011; Bitzer et al. 2008; Goodwin and Agronin 1997.
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Medication Effects
When medication side effects impair sexual function, physicians can consider several options (Goodwin and Agronin 1997; Labbate et al. 2003; Zajecka 2003). The first step is to continue administering the medication and wait for tolerance to develop; many side effects diminish or disappear after several weeks. If no change occurs, dose reduction can be tried. Simplifying the overall regimen might also be helpful, given that combinations of medications can cause more sexual side effects than each medication alone. For certain medications, such as antidepressants that have short half-lives, a drug holiday in which administration of the medication is temporarily stopped for a day or two (such as for a weekend) can result in transient improvement in sexual function (Rothschild 1995). However, there is a risk of recurrence of psychiatric symptoms during this holiday. Ultimately, the clinician may have to consider replacing the medication with an agent that has less potential for sexual side effects, such as bupropion or mirtazapine (Clayton et al. 2014; Reichenpfader et al. 2014). With regard to antipsychotic medications, more potent agents with fewer anticholinergic side effects and prolactin-sparing agents may cause less dysfunction (Baggaley 2008; Serretti and Chiesa 2011).
When sexual dysfunction is due to antidepressant medication, the clinician can also consider using antidotes to reverse sexual side effects (Taylor et al. 2013; Thomas 2003; Zajecka 2003). Antidotes include yohimbine, amantadine, cyproheptadine (a note of caution: cyproheptadine can also reverse the antidepressant effects of SSRIs), bethanechol, methylphenidate, buspirone, bromocriptine (for antipsychotic-induced sexual dysfunction), and the antidepressants bupropion, nefazodone, mirtazapine, and trazodone. The oral erectogenic agents sildenafil, tadalafil, and vardenafil have also been shown to reverse antidepressant-induced ED (Berigan 2004; Fava et al. 2006; Segraves et al. 2007; Taylor et al. 2013). Depending on the chosen antidote for sexual side effects, the patient can take a dose anywhere from 30 to 60 minutes before anticipated sex and can take increasing doses until success is achieved. If intermittent use of an antidote does not work, a regularly scheduled daily dose should be considered.
If none of these strategies work, the clinician must consider the trade-off between the benefits of the original medication and the sexual side effects. For some individuals, stopping the medication poses too great a risk of recurrent psychiatric symptoms, and adequate alternatives may not exist. In this frustrating situation, patients must choose either to discontinue a needed medication or to cope with persistent sexual dysfunction.
Sex Therapy
In some older couples, sexual dysfunction has clear psychological roots; for example, sexual dysfunction often occurs in the context of a dysfunctional relationship. Sex therapy is always best done conjointly, where both partners participate because both are an integral part of the problem and solution. Historically, a psychodynamic model was used in sex therapy to uncover underlying unconscious conflicts, but that approach is now viewed as less successful, and cognitive-behavioral techniques are used in current treatment models (Brotto and Luria 2014; Kaplan 1983, 1974; Westheimer and Lopater 2002). Brief supportive and educational counseling is a first step in treatment and can help dispel distorted and uninformed attitudes toward sexuality in general and toward a sexual problem in particular. Counseling can also help an individual or couple change sexual practices to resolve a problem. In other cases, more intensive couples therapy is needed to resolve long-standing relationship issues before work on a sexual problem can begin.
Sex therapy involves both cognitive and behavioral techniques, with an overall goal of building an association between relaxed and sensual physical intimacy and sexual relations. The same principles can be applied across the life span, with several refinements in late life. Using cognitive therapy techniques, the therapist attempts to change distorted cognitive attitudes toward sexual activity into more practical attitudes. For example, many men with ED find it difficult not to assume the role of a spectator during sex—that is, not to watch themselves with their partners and be preoccupied with the status of their erections. This spectator role can increase anxiety and distract the man from concentrating on pleasurable sensations, with the result that ED is reinforced (Masters and Johnson 1970). To counter this, the man is taught to shift his mental focus from his erection to pleasurable aspects of the encounter (Kaplan 1974). ED may also be perpetuated by cognitive distortions such as catastrophizing, in which the man thinks that if he does not achieve an erection during sex, he will be rejected not only by his partner but by all women. Another common cognitive distortion is all-or-nothing thinking, in which the man thinks that he must achieve an instant erection during sex or else the whole thing is pointless. The problem with such unrealistic cognitive distortions is that they often become self-fulfilling prophesies. The therapist helps the patient to gain insight into the negative effects of such thoughts and then to practice replacing them with more realistic and hopeful ones, sometimes even with positive assertions or affirmations of success (Goodwin and Agronin 1997).
Behavioral techniques used during sex therapy begin with exercises called sensate focus, in which a couple practices physical relaxation techniques during nonpressured sensual touching. Sensate focus helps to reduce performance anxiety and restore the natural flow of the sexual response cycle. Once the partners are able to feel relaxed and physically intimate together without sexual stimulation, they gradually progress to genital stimulation and then intercourse. Several adjustments in these exercises may be required for the older couple. For example, older patients with physical problems that involve some degree of disability may express concerns about being able to exert themselves adequately during sexual activity. The therapist might recommend one of several positions that minimize exertion, such as lying side by side or having one partner kneel on pillows and support himself or herself on a low bed. Other suggestions outlined in Table 14–5 might also apply. Such simple suggestions may remove some of the most anxiety-provoking barriers for an older couple, especially the common but unfounded belief that older persons lack the stamina or dexterity for sexual activity.
During sex therapy, the therapist continues to work with the couple on their relationship and tries to identify and confront resistance that inevitably arises during treatment. Such resistance to these seemingly innocuous exercises often reveals key problems in the relationship that are either causing the sexual dysfunction or impeding its treatment. Regardless of age, many couples find that sexual interest and pleasure reemerge and sexual function improves during sex therapy, allowing them to enjoy once again such a fundamental component of their relationship.
Specific Sexual Disorders
The next four sections will examine in detail several of the more common sexual dysfunctions seen in late life that the geriatric psychiatrist and other clinicians might encounter.
Female Sexual Interest/Arousal Disorder
Female sexual interest/arousal disorder is a significant sexual problem for women across the life span and involves multiple psychological and physical factors (Brotto and Luria 2014). In some older women, loss of libido results from a poor self-image—brought about by age-associated losses of physical strength and beauty—and from changes in sexual function due to cessation of estrogen production during menopause. An older woman’s ability to see herself as a sexual being can be further eroded by exposure to negative societal attitudes and negative images of sexuality in late life. Unfortunately, many women internalize these distorted, ageist beliefs. Treatment of low desire must begin with sex education and counseling to counter those psychological barriers. Estrogen replacement therapy may help improve sexual arousal and comfort, which in turn may lead to increased desire.
The critical physiological cause of low desire in women, however, appears to be the menopause-associated reduction in levels of free testosterone. Testosterone replacement therapy has been beneficial in some women with hypoactive sexual desire (Basson 1999; Buster et al. 2005; Shifren et al. 2006), although side effects can include weight gain, virilization (e.g., growth of facial and chest hair, lowering of the voice), suppression of clotting factors, and even liver damage (Kingsberg et al. 2007).
Erectile Disorder
ED, the most common sexual dysfunction in older men, historically was seen as a psychological problem. More recent data, however, indicate that ED is primarily caused by a problem with erectile physiology in the majority of cases (Ludwig and Phillips 2014; Tariq et al. 2003). There are, however, important psychological components of ED in terms of both cause and effect. Many men equate erections with masculinity, potency, and vitality. As a result, ED in late life is often experienced by men as a harbinger of physical and sexual decline. Performance anxiety, stress, depression, and relationship problems can trigger or exacerbate ED. In turn, ED is associated with feelings of anger, anxiety, powerlessness, shame, and humiliation in front of one’s partner. Recurrent ED can lead to depression.
Treatment of ED in geriatric patients involves the same approaches as those used in younger men and has been revolutionized with the advent of oral erectogenic agents. For men with hypogonadism as the likely cause of ED, testosterone replacement therapy—in the form of a pill, transdermal gel or patch, intramuscular injection, or subcutaneous implant—may be helpful (Howell and Shalet 2001; Jacob 2011; Morley 2003). This treatment should be avoided in men with a history of prostate or bladder cancer or with bladder outlet obstruction. Some men have ED as a result of vascular damage and may benefit from microsurgical revascularization. Peyronie’s disease, characterized by scarring-caused curvature of the penis during erection, can also be treated, with resultant improvement in erectile function.
For many years, the only viable treatments for chronic ED involved either the use of a vacuum constriction device prior to intercourse or the surgical placement of a penile prosthetic device (Dutta and Eid 1999; Sison et al. 1997). Initial pharmacological approaches to ED involved either penile intracavernosal injection or urethral suppositories using alprostadil, a synthetic form of prostaglandin E1, which worked by increasing smooth muscle relaxation and arterial dilatation in the penis (Althof 1995; Padma-Nathan et al. 1997). All of these approaches have given way, however, to the use of the oral erectogenic agents sildenafil, tadalafil, and vardenafil. These agents improve erectile function in men with both organic and psychogenic ED by serving as selective inhibitors of phosphodiesterase type 5 (PDE5). Sildenafil and vardenafil can be taken 30 minutes to 4 hours before anticipated sexual activity, and tadalafil can be taken up to 30 hours prior. Erections do not occur spontaneously on taking these medications but require adequate physical stimulation. The obvious advantages of PDE5 inhibitors are ease of use and success in up to 70%–80% of affected men (Boolell et al. 1996; Porst et al. 2003a, 2003b). Potential side effects include headache, skin flushing, dizziness, gastrointestinal discomfort, blurred vision, and the potential for blood pressure decreases when combined with nitrates (e.g., sublingual nitroglycerin, isosorbide). In addition, the PDE5 inhibitors should be used with caution in men with abnormal penile shape, a history of orthostatic hypotension, severe renal or hepatic disease, concomitant use of certain antiviral and antifungal medications, and diseases that increase the risk of priapism, such as sickle cell anemia, multiple myeloma, and leukemia. An extremely rare but potentially devastating side effect of PDE5 inhibitors that has emerged is nonarteritic anterior ischemic optic neuropathy, or NOIAN (the acronym for the French name for the condition), characterized by the rapid onset of visual loss. Although the exact role of PDE5 inhibitors in the pathogenesis of NOIAN has not been fully established, any changes in visual acuity while taking a PDE5 inhibitor require immediate assessment (Bella et al. 2006).
Female Orgasmic Disorder
Female orgasmic disorder is common in sexually active women of all ages (Graham 2014). It is often comorbid with female sexual interest/arousal disorder and involves many of the same attitudinal barriers to resolution. Many older women who have experienced inhibited orgasm for years resist seeking help, especially if they do not perceive it as a problem for themselves or their relationships. Individual sex therapy involves relaxation techniques that incorporate sensual self-stimulation and guided masturbation to improve clitoral stimulation (Graham 2014; Heiman and Lopiccolo 1976). Both testosterone supplementation and sildenafil have been used with some success (Davis et al. 2008; Nurnberg et al. 2008). When orgasm can be achieved, sensate focus exercises can help to incorporate it into the couple’s sexual relations.
Premature (Early) Ejaculation
Premature ejaculation (PE) is the most common sexual dysfunction in younger men, reported in 20%–38% of various samples, and may remain relatively constant even in older ages (Laumann et al. 1999; Lindau et al. 2007; Porst et al. 2007; Westheimer and Lopater 2002). Ideally, treatment involves psychotherapeutic techniques to slow down perception of sexual stimulation, as well as couples therapy to teach sexual practices to improve PE as well as to deal with its impact on the relationship (Althof 2014). For example, one commonly used behavioral technique is having the partner gently squeeze on the man’s penis before penetration to reduce sensation and stall ejaculation (Althof 2014; Kaplan 1989). Topical anesthetic agents are sometimes useful in reducing the sensations that lead to PE. For persistent symptoms, daily use of an antidepressant medication can often produce the side effect of delaying ejaculation without necessarily affecting erectile function (Waldinger 2007). In addition, PDE5 inhibitors have also been found to effectively treat PE, both alone and in combination with SSRIs (Aversa et al. 2011; Wang et al. 2007).
Sexual Function and Dysfunction in Dementia
Sexuality continues to play an important role in the lives of many individuals with dementia, often by providing a nonverbal means of communication and intimacy. Depending on the degree of cognitive impairment, however, the ability to initiate sexual activity and sustain performance may be impaired. Agitation, disinhibition, and psychosis associated with dementia may give rise to sexually aggressive or inappropriate behaviors. Ethical issues also complicate sexuality associated with dementia. For example, one partner may not be fully competent to consent to sex, especially with another individual who has dementia (Davies et al. 2010), or the nonaffected partner may seek to fulfill sexual needs outside the relationship. It is important to understand these issues when assessing and treating dementia patients and their caregivers. Unfortunately, health care professionals often fail to inquire about such issues, despite the frequency with which they affect couples (Agronin 2014; Robinson and Davis 2013).
Dementia affects sexuality in several ways. Sexual desire may remain strong and even increase, especially if inhibitions are reduced by cognitive impairment. As the dementia progresses, the cognitively intact partner may become concerned about whether the affected individual is truly consenting to sexual activity (Hanks 1992). The partner without dementia may also feel frustrated with a partner who does not always recognize him or her or who requests sex repeatedly because he or she cannot remember when they last had sex (Davies et al. 1992; Redinbaugh et al. 1997). The cognitively intact partner’s sexual desire may decrease because he or she views the dementia and associated changes in behavior and personality as a sexual turnoff. Partners may be further confused by conflicting feelings of love and fidelity for their spouses with dementia, and by guilt over their desires for extramarital intimacy.
It is not surprising, therefore, that there is an overall decrease in sexual activity in affected couples. One study found that 46% of couples were sexually active 3 years after the initial diagnosis of dementia, but the rate dropped to 41% at the 5-year mark and 28% after 7 years (Eloniemi-Sulkava et al. 2002). This decrease may also be attributed in part to sexual dysfunction associated with dementia. For example, cognitive impairment may reduce the capacity for paying attention during sex to maintain a focus on physical and mental stimulation, as well as the ability to initiate and perform components of lovemaking (Rosen et al. 2010). This impairment may explain why men with Alzheimer’s disease have high rates of ED, including more than 50% in one sample (Zeiss et al. 1990), and why inhibited orgasm is common in women with dementia (Wright 1991).
Although the percentage of individuals with dementia who demonstrate sexually aggressive or inappropriate behaviors is relatively small, these conditions tend to generate a disproportionate amount of anxiety for caregivers and to require a disproportionate amount of clinical attention from long-term-care staff (Joller et al. 2013). The problematic behaviors associated with dementia include inappropriate sexual comments or demands, hypersexual behaviors (e.g., repeated requests for sexual gratification, compulsive masturbation), disinhibition (e.g., exposing oneself, disrobing, masturbating in public areas), and sexually aggressive behaviors (e.g., attempts to grope, fondle, or force sex on another person). In various studies, these behaviors were seen in 2%–7% of individuals with Alzheimer’s disease (Burns et al. 1990; Guay 2008; Kumar et al. 1988), although these rates may be higher in institutionalized populations (Hajjar and Kamel 2004b; Mayers 1994). For example, one study found that 25% of residents of a dementia unit engaged in sexually inappropriate behaviors (Hashmi et al. 2000). Because frontal and temporal regions of the brain are involved in behavioral control and inhibition, individuals with dementia affecting these areas of the brain may be particularly vulnerable to developing such inappropriate behaviors (Mendez and Shapira 2013; Raji et al. 2000). Other factors associated with inappropriate or hyperactive sexual behaviors include mania, psychosis, medication effects, alcohol or drug abuse, stroke, and head trauma (Guay 2008; Hashmi et al. 2000; Wallace and Safer 2009).
When assessing an individual who has allegedly demonstrated problematic behaviors, it is critical to identify the context of the behaviors. For example, public disrobing or touching of genitals in public may not be due to sexual urges but may instead reflect underlying confusion, delirium, motor restlessness, or stereotypy associated with dementia. However, caregivers and long-term-care staff sometimes misinterpret innocuous behaviors as evidence of sexual disinhibition (Hajjar and Kamel 2004b; Redinbaugh et al. 1997). A good example would be the aphasic individual with dementia who reaches out or grabs for attention while in his or her wheelchair, inadvertently hitting someone in the waist or chest area. The individual is simply reaching out for help, but the staff member who is touched in the groin or breast area may wrongly view this act as an act of sexual aggression. It is also important to recognize that even individuals with severe dementia have legitimate needs for physical stimulation and intimacy, and these persons may be reacting out of frustration and confusion because they lack the ability to communicate their needs verbally.
The geriatric psychiatrist must be able to address these challenging issues of sexuality in dementia. Regardless of the setting, individuals with dementia have a right to engage in sexual relationships if they still have the capacity to understand the nature of the relationship and provide reasonable consent. If the cognitively intact partner is concerned about the competence of his or her spouse to engage in sexual activity, a psychiatric or psychological consultation may shed light on the affected individual’s understanding of the relationship. Lichtenberg and Strzepek (1990) proposed several questions to be answered in any interview to determine an individual’s capacity to consent to a sexual relationship: Does the individual know who is initiating sexual contact? Can the individual describe his or her preferred degree of intimacy? Is the sexual activity consistent with the individual’s previous beliefs and values? Can he or she say “no” to unwanted activity? Does the individual understand that a sexual relationship with someone other than his or her spouse may be temporary? Can the individual describe how he or she would react if the sexual relationship were to end? Responses to these questions will help determine the affected individual’s awareness of the relationship, his or her ability to avoid coercion and exploitation, and his or her awareness of the possible risks.
One main purpose of psychological or psychiatric intervention is to provide education about sexuality to caregivers in the community and to staff in long-term-care settings. Such education will improve interpretation of and response to apparent inappropriate sexual behaviors. In addition, educational programs for long-term-care staff may foster attitudes that are more open-minded (White and Catania 1982).
Behavioral approaches for inappropriate sexual comments include setting verbal limits and directing the individual to a different topic. Staff and caregivers must be careful to avoid reinforcing inappropriate comments, such as by laughing at off-color jokes or teasing patients in a seductive manner in response to sexual comments. In the case of inappropriate or aggressive sexual advances, staff may need to physically remove the individual from the situation or keep him or her away from vulnerable individuals. Sometimes restrictive clothing (e.g., pants without zippers, pants with suspenders) can cut down on public displays of genitals, although caution must be used so that the individual is not inadvertently restrained. Because sexual advances may reflect unmet sexual needs, existing partners can be asked to consider providing more physical and perhaps sexual intimacy, the hope being that doing so will remove the drive to engage in inappropriate behaviors.
When behavioral approaches are insufficient, psychiatric consultation is needed to provide better control through pharmacotherapy. The choice of medication will depend on the nature and severity of the behaviors and on the presence of underlying psychopathology, if any (Tucker 2010). In general, however, much of sexual aggression can be viewed as any other form of agitation associated with dementia and can be treated accordingly. Thus, a variety of psychotropic agents—in particular, the atypical antipsychotics and antidepressants—may help treat both agitation and sexual problems associated with dementia (Joller et al. 2013; Ozkan et al. 2008). Medications may also be used to treat specific underlying psychopathology. For example, overactive libido can sometimes be reduced through use of an antidepressant with sexual side effects, such as an SSRI or a TCA (Raji et al. 2000; Segraves 1998). If the inappropriate sexual behaviors are believed to reflect hypersexuality due to mania, use of an antipsychotic or a mood stabilizer is indicated. Another pharmacological strategy for decreasing libido and sexual aggression is use of hormone therapy. Estrogen has been shown to reduce aggression in men with dementia (Kyomen et al. 1999), a finding that may be applicable to sexually aggressive behaviors. Medroxyprogesterone is a steroid hormone with antiandrogenic activity that has been shown to reduce sexually aggressive behaviors in individuals with dementia (Light and Holroyd 2006). Potential side effects include weight gain, glucose intolerance, and liver dysfunction.
Key Points
- Because individuals are living longer, healthier lives, sexuality continues to play an important role, facilitated by increasingly positive attitudes and newer and more effective treatments for sexual dysfunction.
- Sexual surveys indicate that although a majority of individuals ages 65 years and older continue to be sexually active, there are declines in both the rate and the frequency of sexual activity, particularly in older single women.
- The main predictors of sexual activity in late life include previous sexual behaviors; the availability, health, and interest of a partner; and the individual’s overall physical health.
- Rates of sexual dysfunction increase with age, with erectile disorder being the most common disorder in older men and sexual interest/arousal disorder being the most common disorder in older women.
- Depending on its form, sexual dysfunction in late life can be treated with a variety of approaches, including treatment of causative medical or medication-related factors, psychoeducation, individual or couples counseling, sex therapy, and the use of disorder-specific medications, such as oral erectogenic agents for erectile dysfunction.
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