Sexuality and Quality of Life in Aging from the Journal for Nurse Practioners

As patients grow older and their comorbidities increase, providers can conceivably overlook the sexual history, perhaps because chronic health problems take precedence during a visit. Other factors also impede opportunities to include important sexual history information. Providers may feel pressed for time, but it is also possible that clinical guideline changes decrease opportunities for providers to discuss sexual health with older adults. For example, routine Pap smears are not recommended for women over age 65, and now men over age 55 do not necessarily receive yearly prostate-specific antigen testing. Instead, men are encouraged to discuss the risks and benefits of routine prostate-specific antigen testing with their health care provider.

Additionally, it is possible that there are barriers to provider-patient discussions about sexuality in aging. Despite the sexual revolution associated with the baby boomer generation, cultural restraints and embarrassment discussing sex may prevent patients from talking about sexuality with their providers,who also may feel uncomfortable discussing sex with older adults.

It is also possible that content-laden curriculums in medical schools and graduate nursing programs may not include information about how to approach this topic with patients. Lindau et al developed and tested a scale to measure nurses' knowledge and attitudes toward aged sexuality with a sample of nurses in 8 nursing homes in Holland. The result is both a Dutch and a Flemish version of the scale. This could be a useful instrument for similar studies with samples of nurses and NPs in the United States and as part of educational programs for NPs on addressing issues about sexuality that patients raise.

Block et al addressed how seniors can enjoy a healthy and mutually satisfying sex life. These authors offered concrete advice on how seniors can continue to enjoy sex, adapting to the challenges of their bodies. Their recommendations include being open to new ideas, trying different positions, varying times of day, and incorporating sex toys into sex play.

Senior Sex: Recommendations for Men

Because erectile dysfunction (ED) is associated with medication side effects, diabetes, coronary artery disease, and other disorders, male patients should be routinely screened for ED in the primary care setting to determine potential causes. Although testosterone replacement is indicated for men with primary or secondary hypogonadism and documented low testosterone levels, it is not indicated for men with normal testosterone levels.According to the American Urological Association (AUA), testosterone is not indicated for the treatment of ED in men with a normal testosterone level.The American College of Physicians determined there was not enough evidence to recommend or not recommend testosterone therapy for ED.

Recent studies also raise increased concerns about testosterone therapy.These studies suggest that men with a past history of cardiac disease seem to have increased susceptibility for a cardiovascular event causing the Food and Drug Administration (FDA) to re-evaluate testosterone's safety. Sildenafil (Viagra; Pfizer, New York, NY) and the other phosphodiesterase-5 enzyme (PDE5) inhibitors (tadalafil [Cialis; Eli Lilly and Company, Indianapolis, IN] and vardenafil [Levitra; Bayer AG, Leverkusen, Germany]) are recommended by the AUA and approved by the FDA for ED. Avanafil [Stendra; VIVUS, Mountain View, CA]) is approved by the FDA. Avanafil, tadalafil, and vardenafil can be prescribed for men over age 65, although there are recommended dosing adjustments with many medications and hepatic and renal drug dosing considerations.

These medications are generally safe, but it is important to note that the side effects of these medications are potentially noteworthy. For example, QT prolongation is a concern with vardenafil and may be a problem when vardenafil is used in combination with other medications that cause QT prolongation.Common side effects of the PDE5 inhibitors include facial flushing, headache, nasal congestion, and stomach upset.PDE5 inhibitors should not be used if the patient is taking organic nitrates, and hypotension is a risk when they are used in combination with alpha-blockers.The AUA also approves alprostadil intraurethral suppositories for ED. These suppositories are particularly effective for ED. However, they must first be used in the practitioner's office because hypotension/syncope can occur. Films, literature, and a variety of devices designed to increase sexual pleasure can help men overcome difficulties with achieving or maintaining an erection and are available on the Internet. For example, penile rings can help a man maintain an erection, and a penile pump can help with achieving an erection. The AUA ED guidelines approve vacuum erection devices with a vacuum limiter for the safe treatment of ED. Of note is that Medicare pays for penile pumps (see www.medicareedpumps.com).

Senior Sex: Recommendations for Women

Women's problems with sexuality as they age are also both physical and psychological. The occurrence of sexual dysfunction in all women has been estimated at 25%-63%. Ambler et al,in a review of the literature on sexual function in older women, noted the paucity of studies and reported that the prevalence of sexual dysfunction may be as high as 68%-86.5%. These authors provide an extensive discussion of the possible physical and psychological factors contributing to these estimates. The most common problems for older women are lack of estrogen, frequent lower urinary tract infections, problems with arousal and achieving orgasm, lack of libido, pain with intercourse, negative body image, and a sense of diminished desirability and attractiveness.

According to Hillman, as women age, their sexuality does not exist in a vacuum because it is shaped significantly by a variety of biological, psychological, social, and cultural factors, as well as environmental and institutional factors. Despite the fact that the research body of knowledge on aging women and the full expression of their sexual activity remain underdeveloped, there is no empirical evidence that women become asexual as they grow older.

Hinchliff and Gott posited that cultural representations of aging and sexuality depict an inaccurate picture for women in later life in which sexual activity no longer assumes importance. This, despite the fact that sexuality is deemed a vital aspect of healthy aging, women rate sex as important or extremely important, and sexual satisfaction is viewed as a component of overall life satisfaction.Loe contended that sex is still seen as men's territory, with women serving as silent partners and that women's perspectives and opinions are largely absent when it comes to the Viagra phenomenon as well.

In addition, the dearth of population-based data about representations of the sexuality of older lesbian, gay, bisexual, transgender individuals is notably missing in the literature. Thompson pointed out the frequent media and cultural heteronormative stigma in which the only kind of sexuality to be valued and condoned is that among healthy heterosexual males. Acknowledgment of the linkage of these factors is vital to examine and address the concerns and needs of aging female adults. For example, an older wheelchair-bound amputee may be physically capable of engaging in sexual behavior, but she elects not to seek out a partner because of an internalized social stigma that older women and physically disabled individuals, of any age or sex, are unattractive and asexual.

From a biological perspective after menopause, vaginal dryness and atrophy can cause discomfort and pain during intercourse. More frequent intercourse and/or vaginal lubricants can be helpful in promoting vaginal lubrication, but many women may not be aware that vaginal estrogen tablets, rings, or creams, when appropriate, help significantly in treating the dyspareunia associated with menopause and the vaginal dryness associated with chronic atrophic vaginitis.

The inability to experience orgasm is a common side effect of selective serotonin reuptake inhibitor antidepressants. This is because the serotonin boost from these drugs decreases dopamine, which leads to sexual problems. It can be beneficial to switch women to bupropion hydrochloride, an antidepressant that does not affect serotonin levels, enhances dopamine function, and improves desire.

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