Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Sexuality and Intimacy Assessment

Sexuality and Aging

 

Human beings are sexual beings throughout their lives. In good health, a person may continue to be sexually active into the seventh, eighth, and even ninth decade (DeHertogh DA, 1994).

Some degree of sexual appetite is usually present throughout life (Brooks TR, 1993).

Persons aged 65 years and older can have satisfying sexual experiences throughout their senior years, and weekly sexual activity is com­mon well past middle age (Janus SC, 2003).

 

Sex involves merging emotional, spiritual and physical intimacies. Quality, in a sense, is more important than quantity when it comes to sexual relations and it comes only with time as the couple get to know each other better (Rao TSS, 2011).

Any performance concerns makes the act only more difficulty The very act of experimenting can lead to failure at times which can be overcome easily in an intimate relationship  (Rao TSS, 2001)

 

Opinions about sex differ across gender and age groups (AARP, 1999).

Having a partner influences a person’s feelings about the importance of sexuality to life quality.

Generally, older adults with part­ners feel that a satisfying sexual relationship is important, whereas those without partners do not feel such urgency.

Women over age 75 are less likely to have a partner than older men and, as such, seem to have a less positive attitude toward or interest in sexual activity than men of the same age.

Men with or without a part­ner have more frequent thoughts, fantasies, and feelings of sexual desire (and self-stimulation) than women, with or without partners (AARP, 1999).

 

Western culture places great value on youth, physical attractiveness, and vigor. The pervasive message, conveyed in countless subtle and not-so-subtle ways, is that aging and sexual desirability are mutually exclusive. We are bom­barded with advertisements for skin creams, cos­metic surgery, and hair color formulas, with the underlying assumption that facial wrinkles, sag­ging breasts, and gray hair are the banes of aging. Older adults may consequently experience lowered expecta­tions for sexual fulfillment and avoidance of intimate relationships due to a sense of unworthi­ness or shame.

 

 

Age-Related Changes and Medical Conditions in Men

 

Decreased desire (loss of libido) can be caused by medical problems, depression, medication side effects, or lack of information about the range of sexual activities that could be pleasurable.

 

ED is the inability to achieve and maintain an erection for successful intercourse.

It is the most prevalent sexual problem in men, and its in­cidence increases with age; approximately 75% of men have experienced difficulty achieving an erection at some time by the time they reach 70 years of age.

Some older men believe that they have erectile dysfunction (ED; once more commonly known as ‘impotence”) when they are actually experiencing an age-related change in physical response.

When compared with younger men, older men require more physical penile stimula­tion and a longer time to achieve erection, and the duration of orgasm may be shorter and less intense.

ED is commonly caused by blood vessel disease associated with hypertension, dia­betes, high cholesterol, and smoking. Neurologi­cal causes of impotence include spinal cord injury and Parkinson’s disease. Impotence can also occur following prostate surgery. Anxiety, depression, and relationship issues may all be im­plicated in ED. Some men suffer from widower’s syndrome, that is, difficulty achieving erection because they harbor guilt about pursuing a sexual relationship after the death of their spouse.

 

Sexual response can also be adversely affected by alcohol consumption.

Testosterone levels have little to do with ED but can have a major in­fluence on libido (sexual desire).

Medications associated with ED include anti­depressants, antihistamines, antihypertensives, antipsychotics, and several over-the-counter preparations (e.g., for heartburn); in most cases, the mechanism for this side effect is unknown.

 

 

Age-Related Changes and Medical Conditions in Women

 

Aging also affects the female sexual response, including fewer and weaker orgasms, mainly due to hormonal changes, but also as a result of al­tered body image, relationship and family issues, and medical conditions that may arise in late life.

Postmenopausal changes in the urinary or genital tract associated with lower levels of estro­gen can make sexual activity less pleasurable. The resulting vaginal dryness and thinning of tissue can cause pain and irritation during intercourse (dyspareunia) and leave fragile mucous mem­branes susceptible to infection.

 

Body image can be particularly important post-mastectomy, which for some women represents loss of a part of their femininity.

 

Any medical con­dition that adversely affects mobility and endur­ance, such as heart disease, diabetes, or arthritis can limit sexual activity and make some positions uncomfortable.

Many of the same medications that are problematic for men can adversely affect the female sexual response; these include antihis­tamines, antihypertensives, antidepressants, anti-psychotics, antispasmodics, antiestrogens, and alcohol.

 

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Patient barriers

 

Even given a desire to discuss sexual concerns with their health care provider, elderly patients can be reluctant due to embarrassment or a fear of sexuality. Others may hesitate because their caregiver is younger than they or is of the opposite sex.(Gott M, 2003) (Poiti MC, 2009)

The attitude of a medical professional has a powerful impact on the sexual attitudes and behaviors of elderly patients, and on their level of comfort in discussing sexual issues.(Bouman W, 2006).

Elderly patients do not usually complain to their physicians about sexual dysfunctions.(Moreira ED, 2005)

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Addressing issues in sexual dysfunction

 

Though sexual desires and needs may not decline with age, sexual function might, for any number of reasons.(Balami JS, 2011) (Bauer M, 2007)

Many chronic diseases are known to interfere with sexual function

Polypharmacy can lead to physical challenges, cognitive changes, and impaired sexual arousal, especially in men.(Bradford A, 2007). However, the reason cited most often for absence of sexual activity is lack of a partner or a willing partner.(Lindau ST, 2007) Unfortunately as one ages, the chance of finding a partner diminishes. Hence the need to discuss alternative expressions of sexuality that may not require a partner.(Bradford A, 2007). Many elderly individuals enjoy masturbation as a form of sexual expression.

 

Men and women have different sexual problems, but they are all treatable. For instance, with normal aging, levels of testosterone in men and estrogen in women decrease.(Hinchliff S, 2011).

Despite the number of sexual health dysfunctions, only 14% of men and 1% of women use medications to treat them.(Lindau ST, 2007). 

With men who have erectile dysfunction, testosterone replacement or other medication may be considered.

For women with postmenopausal (atrophic) vaginitis, estrogen therapy or a lubricant (for those with contraindication to estrogen therapy) can improve sexual function. Anorgasmia and low libido are other concerns for postmenopausal women, and may warrant gynecologic referral.

Loss of physical and emotional intimacy is profound and often ignored as a source of suffering for the elderly.

For elderly adults moving into assisted living or a nursing home, the transition can signal the end of a sexual life.(Hajar RR, 2004).

There is limited opportunity for men and women in residential settings to engage in sexual activity, in part due to a lack of privacy.(Rheaume C, 2008)

The nursing home is still a home, and facility staff should provide opportunities for privacy and intimacy. In a study conducted in a residential setting, more than 25% of those ages 65 to 85 reported an active sex life, while 90% of those surveyed had sexual thoughts and fantasies.(Low LPL, 2005).

Of course, many elderly adults enter residential settings without a partner. They should be allowed to engage in sexual activities if they can understand, consent to, and form a relationship.

 

Sexual needs remain even in those with dementia. But cognitive impairment frequently manifests as inappropriate sexual behavior.

A study of cognitively impaired older adults revealed that 1.8% had displayed sexually inappropriate verbal or physical behavior.(Nagaratman M, 2002). In these situations, a behavior medicine specialist can be of great help.

Health risks of sexual activity in the elderly

 

Sexually active elderly individuals are at risk for acquiring HIV, in part because they do not consider themselves to be at risk for sexually transmitted diseases (STDs).(Nguyen N, 2008). They also might not have received education about the importance of condom use.(Nusbaum MR, 2002).

In addition, prescribing erectile dysfunction medications for men and hormone replacement therapy for women might have played a part in increasing STDs among the elderly, particularly Chlamydia and HIV.(Jena AB, 2010).

The long-term effects of STDs left untreated can easily be mistaken for other symptoms or diseases of aging, which further underscores the importance of discussing sexuality with elderly patients.

Sexual behavior in dementia.

 

Sexual interest and activity does not disappear with onset of a dementing illness.

Those in the first stage of Alzheimer’s disease may experience heightened sexual desire or a complete loss of in­terest in such activity (Tabak N, 2006)

Hypersexuality is rela­tively rare but not uncommon in dementia and can be treated with medication.

Certain medica­tions, such as benzodiazepines, are associated with loss of sexual inhibition (Tabak N, 2006).

 

Assessment of decision-making capacity is es­sential for care home residents involved (or potentially in­volved) in a sexual relationship, with particular focus on

  • comprehension of both parties’ inten­tions or interests

  • their understanding of physical intimacy and sexual activity and

  • their expecta­tions of the relationship and of the activity

If there is evidence that understanding is lacking, then the demented person must be protected from sexual exploitation and abuse, including un­wanted touching.

 

There is no simple answer to the dilemma of a demented person who really wants to be inti­mate or engage in sexual activity but is unable to foresee the consequences, for example, being abandoned, so to speak, after the sexual activity.

In situations like these, an interdisciplinary ethics committee meeting or consultation might be warranted (Kamel HK, 2003).

Among the questions that can be raised are those addressing

  • the impact of this new relationship on the spouse (in the event that one or both are married)

  • the facility’s role in judging the wishes and understanding of the 2 residents

  • the presence or absence of coer­cion, whether either resident (or both) is mistak­ing the other as his or her spouse

  • the extent to which this new activity reflects an authentic value expressed in the past by the resident(s).

 

It is critical to recognize the sexual needs of residents and to make accommodations for these while preserving the rights of others.

For exam­ple, masturbation is a normal (for men and women) way of achieving sexual pleasure in the absence of a partner.

Caregiving staff should re­ceive support and education about how to re­spond when they discover a resident masturbating (i.e., they should take steps to en­sure the resident’s privacy).

Sexual activities that are commonly problematic in long-term care facilities include masturbation in public spaces, disrobing in public, inappropriate or sug­gestive sexual comments, exposing private body parts, reaching out to fondle or grab body parts that are associated with sexual arousal, and at­tempting to kiss others.

These behaviors are dis­tressing to other residents and staff and signal a need for an interdisciplinary sexual assess­ment. The purpose of this assessment is to deter­mine the underlying need the resident is expressing and how it might be addressed. (The possibility of urinary, vulvar, or vaginal pathology should not be overlooked in a resident who frequently touches his or genital area.)

Bore­dom, loneliness, and the need for reassurance can all lead to sexualized behavior that others find objectionable.

 

A resident might be mistaking another person for his or her spouse and begin exhibiting unwel­come intimate behavior toward that person (Kuhn D, 2003).

On the other hand, sexual expression between resi­dents could indicate development of a new legitimate and welcome rela­tionship,

 

loving couple

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Sexuality and Intimacy Assessment

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The Sexuality and Intimacy Assessment is one of 8 domains of the

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