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Geriatric Sexuality

Geriatric Sexuality. Older people were young once too! C. Frank CCFP Oct ‘02. Outline. Myths and expectations research- old and new what changes as we age Talking to older patients about sexuality some specific topics. The writer’s view.

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Geriatric Sexuality

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  1. Geriatric Sexuality Older people were young once too! C. Frank CCFP Oct ‘02

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

  3. The writer’s view • “Wives are young men’s mistresses, companions for middle age and old men’s nurses.” Francis Bacon • “Sexuality in the elderly is a ‘dark continent’ that most people, including physicians, prefer not to think about.” J. LoPiccolo

  4. The writer’s view... • “Forty years of romance makes a woman look like a ruin, 40 years of marriage makes a woman look like a public building.” Oscar Wilde • “These people are just happy to be alive.” Anon

  5. The media’s view...

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

  7. What do you think of when you think of elderly & sex? • ???

  8. Beliefs about sex & aging • Current elderly were ‘Victorians’ when young • sexual desire goes with age • older women who enjoy sex were ‘nymphomaniacs’ when younger • the ‘dirty old man’ • elderly are not “desirable, desirous, capable”

  9. More mythology & viewpoints... • Physiological changes = sexual dysfunction • “cute”, “disgusting”, “troublesome” • physical illness obviates sex & sexuality • Viagra leads to divorces!

  10. How do older people view sexuality? • “I was told nothing until my wedding night and my husband explained it.. For two solid weeks I was in a state of shock.” • despite initial naivete women describe good early attitudes towards sex • minimal change in attitude with aging

  11. Talking with older women... • “The longer you live you start to realize …life is too short… and sex is probably one of the last things to go.” • “You are always a sexual being, until you die.” • “You know, just because we are old doesn’t mean that when I see a nice grey-haired older man.. I take another look.”

  12. Apart from myths, what are other barriers • Physiological changes • lack of privacy • illness & impotence • lack of a partner • negative attitudes from staff & physicians • feeling of unattractiveness • guilt & “widow’s syndrome

  13. Thinking about barriers • “My husband got used to me after 50 years… if I was to start up with a new man now…if we could do it in the dark with our clothes on…” • “There are no single guys out there…not at our age.”

  14. Why do older people stop having sex? • For the same reasons they stop riding a bicycle • fear of falling off (ill health) • afraid of looking ridiculous • lack of a bicycle

  15. What research tells us... • The Kinsey report: general decline interest & activity • M&J: “sharp decline in interest after age 60” • other generally gloomy results

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

  17. Even educated fleas do it... • Large proportion of seniors sexually active: • 54% of married men & women • 65% of women over age 70 • Netherlands: 34 % of women surveyed enjoy sexual activity most of time • Vs. 70% of premenopausal women

  18. Defining sexuality more clearly than Clinton • Women age 80-102: • 25% had regular partner • touching and caressing 64% • masturbation 40% • intercourse 30% • activities often dependent on older partner

  19. Physiology & the pleasure principle • Women: • reduced size of vagina & vulva • decreased vascularity & secretions • thinner, more lax vaginal walls • atrophic vaginitis common • libido declines but rarely disappears

  20. What problems may women report • 43% of older Swedes reported vaginal dryness • 10% vaginal burning • urinary incontinence may occur • dyspareunia • decreased orgasm (30%)

  21. How does the sexual cycle change? • Excitement! • Decreased vasocongestion, lubrication, delayed arousal • Plateau: • expansion of vaginal ‘barrel’, orgasmic platform, clitoral retraction

  22. Cycle changes... • Orgasm: • shorter & fewer contractions • may be painful • Resolution: • more rapid reversion to pre-arousal state

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

  24. Talking to your granny about SEX! • Important indicator of comorbidities • if done appropriately, not offensive • 91% over age 65 felt history-taking was appropriate • remember that identification & education very successful • sexual abuse can still occur

  25. Hearing from the AARP’s • Health-providers should help us feel comfortable talking about sex: • don’t be afraid or embarrassed • help us “break the ice” • offer permission to express feelings & needs

  26. Suggestions to help talking about it • … be open-minded and concerned: • don’t assume there are no concerns • ask direct questions about activity & attitudes • answer honestly • don’t evade sexual concerns

  27. More from the AARP... • …should treat older adults with respectful & non-judgemental attitude • see us as individuals with sexual needs • accept us: gay, straight, bisexual • …can provide advice & suggestions:

  28. What did Kingston women have to say? • “So, how’s your sex life?” not a great line • valid question if an explanation is given • would talk to their MD if something specifically wrong • layman’s terms, avoid making patient feel complaint insignificant

  29. Getting better informed about specific topics • Menopause • “ED” • dementia • sexual abuse • chronic illnesses

  30. Menopause: just a few controversies • Treatments: • HRT (local and oral) • education of woman & partner • ?testosterone ?Viagra • lubricants • education about male partner’s aging changes

  31. The myth of male menopause? • Controversial! • ?aging associated with lower sex steroid levels • levels of binding globulin increases • pituitary, adrenal and testicular causes • less dramatic & less rapid than with women

  32. What might it mean? • testosterone likely plays smaller role in ED • many men try androgens to help erectile dysfunction • frailty: osteoporosis, decreased muscle mass

  33. How to look for it?

  34. Viagra: an interesting sociological study • Pfizer stock is a star! • US army spending $$$ on it

  35. Listening to Viagra • “Dr. Ian Osterloh may be one of the most important men in American history, if not world history”

  36. Viagra:the first of many • inhibits phosphodiesterase • elevates serum levels of cyclic guanosine monophosphate • effect is on erectile dysfunction not libido

  37. Viagra:the first of many

  38. How to use it? • taken orally 50 mg 1 hour before planned intercourse • achieve erections in up to 85% of men • be aware of safety concerns- good assessment of comorbidities

  39. Who to be cautious with • Active coronary ischemia • active CHF • hypotension/hypertension • liver/renal failure • interacts with cimetidine, erythromycin • frequent users!!!

  40. New kids on the block? • Vardenefil - can be taken with food! • tadalafil • apomorphine- ??2003

  41. Dementia & Sexuality • Barriers to intimacy: • agnosia • social cues • sexual disinhibition • caregiver stress • depression (s)

  42. Sexual abuse and older people • Fits definition of “Elder Abuse” • remote history of abuse • depression • anxiety • adjustment disorders • resource limitations

  43. Sexuality and medical conditions • Cardiac disease • stroke • COPD • Diabetes

  44. Ae’ fond kiss and then we sever

  45. Sexuality and the older adult • Be aware of the issue • knowledge of aging changes important • comfort in communication • expertise in specific topics helpful

  46. If it’s not too effective, is it safe? • Weight gain, gynecomastia, sleep apnea • MI, stroke • altered lipids, ? Polycythemia • prostate cancer?

  47. How to answer patients’ questions? • Consider screen for testosterone,highest level in AM • if low, check FSH, LH, prolactin • could consider Tx for libido problems • not likely great for lost vigor and soft body!

  48. If it works for young men can it work for older men? • Testosterone given IM to 13 men 57-76 years old with low serum testosterone • increased lean body mass but no change in % body fat, grip strength, bone parameters • increased PSA • less clear benefit than in younger men

  49. Tx options they might read about on the Internet? • Oral testosterone- serious hepatotoxicity • parenteral- may cause fluctuation in levels • transdermal- scrotal or non-scrotal • more physiological levels • scrotal patch causes high DHT

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