Abstract
Abstract
There is a substantial increase in the total geriatric population worldwide. This change in demography calls for a greater, deeper, and thorough understanding of elderly and age-related issues. Even though sexuality is a basic and vital driving force, human sexuality, especially elderly sexuality, is frequently misunderstood. Many myths and misconceptions regarding elderly sexuality exist which need attention. Contrary to the popular belief, studies reveal that sexual life continues to be an important aspect in later life and is often viewed by elderly as an expression of love, passion, affection, admiration, and loyalty. Various factors play a role in elderly sexuality including that of bio-psycho-social factors, changes in the body, presence of comorbid conditions along with sexual disorders. Sexual disorders, if present, should be treated and addressed adequately.
Introduction
As the population of persons of age 65 and above grows and the population of baby boom generation ages, there will be a substantial increase in the total geriatric population worldwide. This predicted change in demography calls for a greater, deeper, and thorough understanding of elderly and age-related issues. Regardless of how long a person lives, the experience of human closeness remains important, and in this regard sexuality remains an important component of emotional and physical intimacy. Even though sexuality is a basic and vital driving force, human sexuality is frequently misunderstood. 1
In general, people view sexual intimacy and sexuality in older people in many ways. Firstly, there is an unspoken and unwritten societal rule that “old” people do not and should not have sexual intimacy and that they should be asexual. Secondly, some view sexuality based on a false notion that physical attractiveness depends on youth and beauty. Some believe that people do not have sexual needs in their older age. The asexual behavior of the elderly is stereotyped to an extent that there are comical cards, internet jokes, and messages about physical weakness and failures in sexual performance. On the other hand, elderly themselves are reluctant to speak about their sexual desires and feelings, for the fear of being seen as immoral, suggesting the deeply ingrained societal and cultural belief system of unacceptance towards sexual intimacy in the elderly.2, 3 These lead to many myths and misconceptions4, 5 in the society and these can be discussed with the treating physician or collaborating specialists.
Studies reveal that sexual life continues to be an important aspect in later life and is often viewed by elderly as an expression of love, passion, affection, admiration, and loyalty. 6 It gives them a means of affirming physical functioning, sense of identity, and self-confidence. Furthermore, studies have revealed that the sexual desire does not change with advancing age; however, sexual ability may be affected by sexual dysfunction.
Sexual functioning is a combination of bio-psycho-social process 7 meaning to say that sexual functioning is influenced by 3 main domains that is the drive (biological), the will (psychological), the wish (social context), and the interaction between these three domains which is then coordinated by neurological, vascular, and endocrine system.
The will, that is, psychological factors are main determinants of intensity of sexual desire and are independently related to sexual functioning. Social context or the wish (e.g., partner availability, duration of relationship, cultural influences) plays an important role in sexual function. There is an overall correlation between happiness and sexual well-being. Attitudes about sex and sexuality are also important influence on frequency of partnered sexual activity.
Various factors affect sexuality in elderly, for example, marital status, primary sexual attitudes and values inculcated from childhood, religious background, intrapsychic conflicts like performance anxiety, interpersonal issues, awareness about sexuality, and educational status. 8
Changes in Body
As age advances there is an overall decline in normal bodily functions including metabolism, immunity, cognition, activities of daily living and sexual functions.
In males, after the age of 50, there is decrease in levels of testosterone. Physiologically speaking, sexual functioning changes with ageing. It has been documented in few studies that about 50% of men experience impotence by the time they reach the mid-70s. 9 The reason behind this can be attributed to various factors which can be broadly categorized into two factors or the combination of both—organic, that is, due to effect of disease like hypertension, diabetes mellitus, and cardiac conditions, or due to medications like diuretics; or psychological, that is, due to anxiety, guilt, and depression.
It is estimated that by the time a male is in his 40s, there is 40% chance of having some form of erectile dysfunction (ED) and the prevalence increases about 10% per decade thereafter. 10 Penile rigidity declines gradually after the age of 60. Mostly penile rigidity remains adequate for vaginal intercourse, but couples may require extended foreplay, manual stimulation, or try different positions to achieve full penile erection for penetration. 11
Furthermore, the time required in achieving orgasm and the duration of orgasm decreases with age, this may be explained by less intense prostatic and urethral muscle contractions with decrease in ejaculatory force. 12 In some cases orgasm may occur without ejaculation. As age progresses, there is gradual decline in semen volume per ejaculation. It has also been documented that the length of refractory period decreases. 13
In women, decline in sexual interest and desire is more frequently reported as compared to males. The estimated prevalence of sexual dysfunction among women is estimated to be between 25% and 65%, and the prevalence in postmenopausal women is even higher, with rates between 68% and 87%. 14 The higher prevalence of sexual dysfunction in elderly age group can be explained due to decreased sexual desire which is caused by decreased vaginal lubrication (loosely termed as “wetting”) and thinning of vaginal lining leading to pain during vaginal intercourse, and in such cases adequate gynecological treatment is warranted.
Age-Related Problems, Diseases, and Sexuality
Arthritis: Joint inflammation causes pain and difficulty in movements which may lead to negative image of the self. It has been postulated that at some level arthritis causes inflammation in the penile vessels which may contribute to erectile dysfunction. 15 Sexual dysfunction in men and women can also be attributed to the increased fatigability and restricted joint movements.
Hypertension: This is a chronic medical illness and is quite common. Long-term hypertension can cause stroke, heart failure, and renal diseases. Hypertension causes dysfunction in the vascular and endothelial systems and hence can affect the ability of the arteries to dilate and contract and may lead to erectile dysfunction in men and vulvar and vaginal congestion in women. Erectile dysfunction is a common complaint in hypertensive men and it may signify an underlying systemic vascular disease. 16 Erectile dysfunction is considered as an early marker of cardiovascular disease. 8
Obesity, body mass index: Obesity can cause hypertension, diabetes, atherosclerosis in the long run. 17 A study had shown that obesity is linked with erectile dysfunction 18 in men older than 60 years, perhaps due to the vascular effects of obesity and its effect on penile blood flow. Another set of studies showed that there is about 30% reduction in testosterone in men with BMI more than 30 and men who were overweight were at an increased risk of developing erectile dysfunction regardless of the weight loss during the follow-up period. 19
Atherosclerosis and vascular disease: Atherosclerosis is associated with heart related-problems and also with the vascular system including the coronary arteries and hence indirectly causing problems in achieving erection. 18 About 30% of men with vascular disorders experience sexual dysfunctions and most of the women report of altered desire and frequency of intercourse. 5
Diabetes mellitus: This disease is commonly associated with problems related with sexual functioning. In men, it may lead to decreased sexual desire and difficulty in attaining erection. It has been documented that about 60% of males with type II diabetes mellitus develop sexual dysfunction within 5 years of disease onset. 20 The causes of erectile problems in diabetes may be attributed to the neurogenic, vascular and muscular reactivity, and arterial insufficiency. Women with diabetes mellitus may face decreased sexual desire, inability to reach orgasm, and difficulty in obtaining vaginal lubrication; however, studies could not find any correlation of sexual functioning in women with duration of diabetes, age, or insulin use. 21
Cerebrovascular accidents or stroke: A stroke may cause dysfunction in the autonomic system which may lead to post-stroke sexual dysfunction. It is estimated that about 20% to 75% of people having stroke have sexual dysfunction. 22
Prostate illness: Lower urinary tract symptoms (LUTS), such as dribbling of urine and urgency to pass urine, are commonly associated with benign prostatic hypertrophy. Deterioration of quality of life caused by prostate diseases may be affected not only by the prostate diseases themselves but also by the sexual dysfunction caused by the prostate diseases secondarily. 23 Few studies have revealed that LUTS is associated with erectile and ejaculatory dysfunction. 24
Depression: This develops as a result of complex interplay between multiple factors such as environmental, psychological, and genetics; these factors then cause alteration in the neurochemical system of the body resulting in the symptoms of depression, ultimately affecting all the functioning of the body including sex. 25 Depression may cause decreased libido, excessive guilt, lack of desire, and anorgasmia. 26
Alcohol: Intake of alcohol suppresses testosterone concentrations. 27 In addition to this, chronic alcohol consumption is associated with liver cirrhosis and liver failure which leads to low concentration of testosterone. Heavy alcohol use over a long period causes erectile dysfunction which might be irreversible in some cases. 28
Smoking: Smoking is associated with erectile dysfunction 29 ; this is due to direct toxic effects on the vascular endothelium and may be due to decreased levels of testosterone.
Cannabis: At high doses, cannabis inhibits the hormones and hence reduces fertility. Some studies also suggest that frequent cannabis use may be associated with higher number of sexual partners and this may indirectly cause difficulty in achieving orgasm. 30
Common Sexual Dysfunctions
Sexual dysfunction may occur at any age; however, it is more commonly encountered in the elderly. Diagnostic and Statistical Manual of Mental Disorders
(Fifth Edition) (DSM-5) includes the following: (a) disorders of desire, interest, and arousal. These are subcategorized into male hypoactive sexual desire disorder, female sexual interest/arousal disorder, and male erectile disorder. (b) Orgasm disorders which include female orgasmic disorder, delayed ejaculation, and premature (early) ejaculation. (b) Sexual pain disorders which include genito-pelvic pain/penetration disorder. (d) Sexual dysfunctions due to general medical conditions.
Female sexual interest/arousal disorder: DSM-5 has combined female sexual desire disorder and arousal disorder into one diagnosis of female sexual interest/arousal disorder. It is characterized by reduced or absent sexual interest or arousal which may manifest as reduced interest, reduced erotic thoughts, absent or reduced initiation of sexual activity, reduced sexual excitement or response to erotic external cues, or reduced genital sensations during sexual activity.
Male hypoactive sexual desire disorder: Generally speaking, hyposexuality or decreased desire for intercourse and intimacy is seen as a part of ageing. Hyposexuality may be due to changes in hormonal levels or due to comorbid conditions like diabetes mellitus or hypertension. DSM-5 describes male hypoactive sexual desire disorder as persistently deficient or absent sexual thoughts, fantasies, and desire for sexual activity for a duration of at least 6 months. The symptoms can be acquired or lifelong, situational or generalized. It has been classified into mild (mild distress over the symptoms), moderate (evidence of moderate distress over symptoms), and severe (evidence of severe or extreme distress).
Male erectile disorder: Erections are usually produced by complex integration of hormones, nervous system, and vascular system. Erectile dysfunction is the inability to achieve or maintain an erection sufficient for a satisfactory sexual performance. It includes difficulty in obtaining or maintaining erection during sexual activity, or decrease in penile rigidity. It affects about 50% males older than 40 years.
Female orgasmic disorder: This is also known as inhibited female orgasm or anorgasmia. DSM-5 defines it as inhibition of female orgasm and is manifested as delay or absence of orgasm after a normal sexual excitement phase, and is present in almost 75% to 100% occasions of sexual activity. The duration criterion is 6 months. It may be lifelong or acquired, generalized or situational. According to severity, it can be classified as mild, moderate, or severe. Various psychological factors are associated with it. They include poor body image, feelings, or guilt. Cultural and social restrictions also play an important role.
Premature ejaculation: This refers to a persistent or recurrent pattern of ejaculation occurring during sexual activity with a partner. The usual cutoff time is around 1 minute after a vaginal penetration or before the wish of individual for at least 6 months. It is mostly due to psychological issues such as anxiety and guilt. DSM-5 further categorizes it as either lifelong (if present since individual is sexually active) or acquired (disturbance occurring after normal functioning), and generalized or situational. Premature ejaculation can be mild (30 seconds-1 minute), moderate (15-30 seconds), or severe (<15 seconds).
Genito-pelvic/penetration disorder: Due to the lack of supporting data for vaginismus and dyspareunia, which comprised a separate entity for diagnosis in DSM-IV, these disorders have been combined together into a new category of genito-pelvic/penetration disorder. Patients with this disorder have difficulty having intercourse, complain of genito-pelvic pain, and tension of the pelvic floor muscles making intercourse an unpleasant experience. This can be caused by various factors such as anxiety about the act, or physiological changes during postmenopausal period, or history of sexual abuse.
Dhat syndrome: It is a culture-bound syndrome of sexual dysfunction. Patients with Dhat Syndrome complain of asthenia, anxiety, depression, and phobia. The symptoms are attributed to loss of semen, nocturnal emission, bad dreams, or nocturnal emissions.
Post-coital dysphoria: Is a counter-intuitive phenomenon characterized by inexplicable feelings of tearfulness, sadness, or irritability following otherwise satisfactory consensual sexual activity. It is currently not listed under any classificatory system. Contrary to problems related to desire, arousal, and orgasm which have been subjected to extensive research, post-coital reactions and feelings are under-recognized and under-researched.
Management
Diagnostic Workup
The first step for effective management lies in establishing adequate rapport in an environment where the patient is comfortable. An extensive detailed history needs to be collected with more emphasis on the areas of concern. The detailed history-taking starts from taking the sociodemographic details, relationship status, and sexual orientation. The patient is then enquired on the sexual functioning which includes sexual desire, libido, frequency of intercourse, description of sexual interactions, including foreplay and the overall satisfaction from sexual functioning. History on the current sexual complaints, stressors, sexual practices, relationship issues, sexual fantasies, partners, masturbatory practices, reproductive history, use of contraceptives, or any exposure to sexually transmitted diseases (STDs) or high-risk sexual behavior should be taken into account. 28 Details on psychiatric illness, if any, and comorbid medical illnesses should be thoroughly enquired and organic causes should be ruled out.
After the history-taking, a thorough physical examination is required, an informed consent and privacy of the patient must be ensured. Laboratory tests including urine analysis, complete blood count, kidney and liver function tests, lipid profile, fasting blood sugar, thyroid function tests, and electrocardiogram (ECG) must be done. Depending on the case and procedure being planned, tests such as nocturnal penile tumescence and pelvic penile angiography can be requested.
Psychological Interventions
Sex therapy is most commonly used for sexual disorders. It is a brief problem focused approach which involves both partners. It includes educating the individuals on anatomy and physiology of sexual organs, enhancing interpersonal communication without blaming self or partner, teaching of sensate focus exercises. 29 Other therapies such as couples therapy, family therapy, and cognitive behavioral couple therapy can also be used. The assessment and treatment needs to be tailored depending upon patient profile and needs, setting and type of problem encountered.
Pharmacological Management
Female sexual interest/arousal disorder: The first US-FDA approved molecule to treat desire and arousal disorders in females is flibanserin. It is a potential non-hormone treatment option. 30 It affects neurotransmitters such as serotonin (5HT1A, 5HT2A, 5HT2B, 5HT2C receptors), dopamine (D4 receptor), and norepinephrine. It is administered as 50 mg to 100 mg once or in 2 divided doses.
Topical (intravaginal) use of dehydroepiandrosterone (DHEA) has shown promising results in treatment of low sexual desire in women. 31 Transdermal testosterone (300 µg day–1) has shown improvement in sexual desire and in frequency of sexual activity. 32
Bupropion which is a norepinephrine dopamine reuptake inhibitor have shown promising results in antidepressant—induced desire disorder. 33
Male hypoactive sexual desire disorder: First approach in treatment hypoactive sexual desire disorder is to treat psychiatric comorbidities such as depression, anxiety disorders, and psychotic disorders. Hypogonadism and low testosterone levels contribute to low desire.
Depression is an established cause for low sexual desire and its treatment leads to reestablishment of desire.
Antidepressants such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) are linked with sexual side effects like anorgasmia 34 and low sexual desire. 35 This can be managed with bupropion and nefazodone.
Psychotic disorders are, in some cases, associated with low sexual desire. Treatment with antipsychotics may be helpful.
Male erectile disorder: First line drugs for treatment for erectile dysfunction are Phosphodiesterase-5 (PDE-5) inhibitors which include sildenafil, vardenafil, tadalafil, avanafil, and udenafil. As the name suggests, these block PDE-5, which hydrolyses cyclic guanosine monophosphate (cGMP) in the corpora cavernosa. Thus, cGMP accumulates causing smooth muscle relaxation and increase in the blood flow which then compresses the subtunical venous plexus leading to penile erection. 36 PDE-5 inhibitors are contraindicated if patients are receiving nitrates and dose adjustments are required with concomitant use of CYP3A4 inducers and inhibitors.
Sildenafil, which was launched in 1998, is rapidly absorbed after oral administration. Half-life of sildenafil is 2.5 to 4 hours and it takes about 30 to 120 minutes (median 60 minutes ) to reach maximum plasma levels. It is administered 1 hour before intercourse. If taken along with fatty meals, there is prolonged absorption of about 60 minutes. Dose adjustments are required in elderly, especially for age more 65 years. Clearance is reduced in individuals with renal insufficiency and hepatic impairment. Side effects include headache (13%), flushing (10.4%), nasal congestion, and alteration in color vision (1%-4%). These effects are usually transient and mild. 37
Sildenafil is available in doses of 25 mg, 50 mg, and 100 mg. The recommended starting dose is 50 mg which can then be titrated up. 38
Tadalafil reaches maximum plasma concentration in 30 to 360 minutes (median 120 minutes), its half-life is about 17.5 hours, and is taken 30 minutes to 1 hour before intercourse. 39 Absorption of tadalafil is not affected by food. It should be used with caution in elderly. Dose adjustments are required in hepatic and renal impairments. The recommended starting dose is 10 mg and can be titrated up till 20 mg for on-demand treatment. Adverse effects include headache (14.5%), dyspepsia (12%), myalgia (7%), and nasal congestion (4%).
Vardenafil is effective 30 minutes after administration. Its absorption is reduced by fatty foods. It is available as 5 mg, 10 mg, and 20 mg tablets. Recommended starting dose is 10 mg and can be titrated up as per response. Time to reach maximum plasma concentrations ranges between 30 and 120 minutes, it has a half-life of about 4 hours. Like sildenafil and tadalafil, dose adjustments are required for elderly patients. Adverse effects include dyspepsia, myalgia, and nasal congestion. 40
Udenafil has a longer half-life of about 11 to 13 hours and time to reach maximum plasma levels is about 60 to 90 minutes. 40 Its onset of action is within 30 minutes of drug administration. It can be given 1 to 12 hours before intercourse. Adverse effects include headache, flushing, and blurred vision.
Avanafil, is a recently launched drug, approved by US-FDA in 2012. Avanafil has a half-life of about 5 hours and reaches peak plasma levels within 30 to 45 minutes. It is available as 100 mg and 200 mg tablets; recommended starting dose is 100 mg once a day. However, if the individual is on alpha blocker therapy it may be initiated at 50 mg day–1. Depending upon tolerability and efficacy it can be increased to 200 mg day–1. It is administered 15 to 30 minutes before sexual activity. Dose adjustments are usually not required for mild-moderate renal and hepatic impairment; however, its safety and efficacy is not established for severe renal or hepatic impairment and this is not recommended for use in such scenario. It is generally well tolerated 41 ; adverse effects include headache (5.6%), flushing (3.5%), and dyspepsia and nausea (<2%).
Female orgasmic disorder: Use of PDE-5 inhibitors, such as tadalafil, vardenafil, and sildenafil (dose range 25mg-50 mg) have shown mixed results.
Androgen replacement therapies such as testosterone, DHEA, oral testosterone with estrogen have been studied, but studies included women with sexual desire disorders as well, making it difficult to interpret the results. Testosterone therapy has long-term implications including that of hirsutism, acne, and masculinization. Replacement therapy with estrogen leads to coronary heart disease, thrombosis, and stroke; hence, hormonal therapies should be used cautiously for treatment of orgasmic disorders. Tibolone has been shown to improve orgasmic dysfunction 42 in some studies; however, more studies are required to establish its effectiveness.
l-Arginine has demonstrated positive results in a placebo-controlled study. 43
Orgasmic disorders can be caused by SSRIs as well; hence, a thorough drug history is required for developing treatment strategy. Adding amantadine (dopaminergic substance) or PDE-5 inhibitor is commonly used for treating SSRI-induced orgasmic dysfunction.44, 45 In some cases, switching to a different antidepressant such as agomelatine, bupropion, and mirtazapine may be a better option.46, 47
Premature ejaculation: Pharmacological agents such as SSRIs, PDE-5 inhibitors, alpha adrenergic blockers, and topical anesthetic agents have been used with satisfactory benefits. Daily SSRIs are used as off-label agents for premature ejaculation. Drugs like fluoxetine 20 mg to 40 mg, paroxetine 10 mg to 40 mg are well tolerated. Ejaculatory delay can be seen in 5 to 10 days of drug treatment but full therapeutic effects are achieved in 2 to 3 weeks. Adverse effects such as nausea, sedation, and diarrhea can occur. Paroxetine can cause hypoactive sexual desire disorder and erectile dysfunction; however, it is rarely reported. Some clinicians prefer using SSRIs as on-demand basis (3-6 hours before intercourse) but is less effective than daily dosing. 48 Dapoxetine, an SSRI, is the first compound designed specifically for treatment of premature ejaculation. It is used in dose range of 30 to 60 mg and administered 1 to 2 hours before intercourse. 49 Studies have revealed significant increase in intravaginal ejaculatory latency time, greater control over ejaculation, and satisfactory intercourse; however, robust studies are needed to ascertain long-term efficacy.
PDE-5 Inhibitors are used alone or in combination with SSRIs. Use of PDE-5 inhibitors in premature ejaculation is speculative. 50 Off-label use of alpha 1 adrenergic antagonists like terazosin have shown to increase intravaginal ejaculatory latency time.
Genito-pelvic/penetration disorder: Topical ointments with anesthetic properties have been recommended for these disorders. A study done by Boardman et al revealed that topical gabapentin is well tolerated and associated with pain relief 51 in such disorders; however, more studies are required. Tricyclic antidepressants have shown some improvement.
Treatment is dependent on identification of all components of pain. Psychological, interpersonal, and cultural dynamics must be addressed and hence multidisciplinary management is required which includes medication, physical therapy, psychological therapy, and, when indicated, surgery. 52
Dhat syndrome: Depressive symptoms of Dhat syndrome can be managed by treating with SSRIs. Anti-anxiety agents like benzodiazepines have been also used. Psychoeducation about the anatomy and physiology of sex organs and their functioning can be explained; relaxation therapy which includes relaxation exercises like Jacobson’s progressive muscular relaxation technique (JPMR) can be practiced 2 to 3 times daily. 53
Conclusion
Human sexuality being a basic driving force is frequently misunderstood. Sexual life continues to play an important role in elderly as it is one of the major factors needed for emotional and physical intimacy. Sexual function and activity are linked closely with physical health. Various factors play a role, example, psychological factors or the will, social context or the wish.
Culture holds an important role in understanding the concepts of sex for example, sex-positive cultures, which view sex as a pleasurable act or sex-negative cultures which view sex as fundamentally procreative and reject recreational role for sexual activity, hence modifying the treatment path. Sexual disorders need to be assessed thoroughly for adequate treatment strategies.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.