Audio at CurrentPsychiatry.com Dr. Chow: The differential diagnosis of sexual dysfunction When it’s time for ‘the talk’: Sexuality and your geriatric patient A sexual history is an essential part of the comprehensive psychiatric evaluation ecent studies suggest that most older adults main- tain sexual interest well into late life; many, however, Rexperience sexual dysfunction. This article provides psychiatric practitioners with current information regard- ing sexuality and aging, as well as psychiatric and systemic medical comorbidities and sexual side effects of medi- cations. Practice guidelines for assessing and managing sexual dysfunction have been developed for use in many medical specialties, and such guidance would be welcome in psychiatric practice. This article addresses the myth of “geriatric asexuality” and its potential impact on clinical practice, the effects of age-related physiological changes on sexual activity, the ©DAVE CUTLER©DAVE importance of sexuality in the lives of older adults, and Elaine S. Chow, MD sensitive questions clinicians can pose about geriatric sexu- Michael G. DeGroote School of Medicine ality. We also will discuss: Faculty of Health Sciences • the importance of including a sexual assessment in the McMaster University Hamilton, Ontario, Canada comprehensive psychiatric evaluation Ana Hategan, MD • recognizing sexual dysfunction Associate Clinical Professor • providing appropriate management within a multi- Department of Psychiatry and Behavioural Neurosciences disciplinary, collaborative approach. Division of Geriatric Psychiatry Michael G. DeGroote School of Medicine Faculty of Health Sciences McMaster University Sexuality after 65 Hamilton, Ontario, Canada Regardless of age, sexual activity can provide a sense of com- James A. Bourgeois, OD, MD Clinical Professor fort and elicit a positive emotional and physical response.1 Vice Chair Clinical Affairs Hillman2 defined human sexuality as any combination of sex- Department of Psychiatry Langley Porter Psychiatric Institute ual behavior, emotional intimacy, and sense of sexual identity. Consultation-Liaison Service University of California San Francisco Medical Center Disclosures San Francisco, California The authors report no financial relationships with any company whose products are Current Psychiatry mentioned in this article or with manufacturers of competing products. Vol. 14, No. 5 13 continued Sexuality in the aging population gen- psychiatrist suggests that Mr. C and his wife erally is an understudied area, obscured undergo couples counseling. by the myth of “geriatric asexuality” and subject to numerous psychosocial vari- ables.1 Previous research, focused on a bio- Physiological changes with aging logical perspective of sexuality, has largely In both women and men, the reproductive overlooked psychological and social influ- system undergoes age-related physiologi- Geriatric ences.3 It has been assumed that, with age, cal changes. sexuality physical and hormonal changes or chronic illness ordinarily reduce or eliminate sex- Women. In women, the phase of decline in ual desire and sexual behavior.3 However, ovarian function and resulting decline in the majority of older adults (defined as sex steroid production (estradiol and pro- age ≥65) report a moderate-to-high level of gesterone) is referred to as the climacteric, sexual interest well into late life.1,3 with menopause being determined retro- Sexual function remains a subject often spectively by the cessation of a menstrual neglected in psychiatry. Sexual dysfunc- period for 1 year.5 Clinical Point tions, as described in the DSM-5,4 do not Menopausal symptoms typically occur Invite the patient include age-related changes in sexual func- between age 40 and 58; the average age of tion. In addition to physiological changes, menopause is 51.6,7 Both estradiol and pro- to discuss his (her) sexual difficulties can result from relation- gesterone levels decline with menopause, sexual life; this can ship strain, systemic medical or psychi- and anovulation and ovarian failure ensue. convey a sense of atric disorders, and sexual side effects of A more gradual decline of female testoster- respect, control, medications. one levels also occurs with aging, starting in the fourth decade of life.8 and empathy CASE REPORT Clinical manifestations of menopause Mr. C, age 71 and married, is being treated include vasomotor symptoms (ie, “hot for a major depressive episode that followed flushes”), sleep disturbances, anxiety and a course of shingles and persistent posther- depressive symptoms, decreased bone min- petic neuralgia. Medications are: escitalo- eral density, and increased risk of cardio- pram, 20 mg/d; pregabalin, 150 mg/d; and vascular disease.6,7 Loss of estrogen as well ramipril, 5 mg/d. Mr. C is physically active as continued loss of testosterone can result and involved in social activities; he has no in dyspareunia because of atrophy and substance use history. He attends clinic visits decreased vulvar and vaginal lubrication, with his wife. with sexual excitement achieved less quickly, Mr. C reports that despite significant and a decreased intensity of orgasm.7 improvement of his depressive and pain symptoms, he now experiences sexual dif- Men. Research has shown that testosterone ficulties, which he seems hesitant to discuss levels are highest in men in the second and in detail. According to his wife, Mr. C appears third decades, with a subsequent gradual to lack sexual desire and has difficulty initi- decline.9 Older men with a low testosterone ating and maintaining an erection. She asks level are described as experiencing “late- Mr. C’s psychiatrist whether she should stop onset hypogonadism,” also known by the her estrogen treatment, intended to enhance popularized term “andropause.”10 This is her sexual function, given that the couple is attributed to decreased activity at the tes- no longer engaging in sexual intercourse. ticular and hypothalamic levels.10 Discuss this article at Mr. C admits to missing physical inti- Nonetheless, only a small fraction of www.facebook.com/ macy; however, he states, “If I have to make older men with confirmed androgen defi- CurrentPsychiatry a choice between having sex with my wife ciency are clinically symptomatic.11,12 Low and getting this depression out of my head, testosterone is associated with decreased I’m going to pick getting rid of the depres- libido; it can hinder morning erections, sion.” Mrs. C says she is becoming dissatisfied contribute to erectile dysfunction, and with their marriage and the limited time she result in erections that require physical Current Psychiatry 14 May 2015 and her husband now spend together. Mr. C’s stimulation.13 continued on page 16 continued from page 14 Table 1 Strategies for taking a sexual history Invite the patient to discuss his (her) sexual life; this can convey a sense of respect, control, and empathy, and emphasize that this type of information sharing is important for care Explore a geriatric patient’s participation in sexual behaviors, regardless of marital or health status (eg, in addition to sexual intercourse, ask about masturbation, non-coital sex, visits to sex workers). Consider exploring this during the review of systems or during the review of psychosocial history Geriatric Ask the primary care physician to provide findings from a recent physical examination and routine sexuality laboratory findings as part of the intake procedure for psychiatry referrals or consultations; this can provide opportunities for guided discussion and further medical investigations and/or specialty referrals (eg, referral to a diabetes care team or urologist) Ask geriatric patients to bring all of the medications they take during the week, including prescription and over-the-counter medications and supplements; this can provide more accurate information than asking for verbal reports If sexual dissatisfaction or sexual dysfunction is reported, ask about the specific stage of sexual experience in which this occurs (eg, difficulties with arousal, erection, dyspareunia, ejaculation, orgasm) Obtain a psychiatric, medical, and social history (eg, depression, anxiety, type 2 diabetes mellitus, Clinical Point hypertension, marital strain), which can reveal causes of the sexual dysfunction In a survey of older men and women, Notably, erectile dysfunction involves and problems in >3,000 older community- those who reported several other etiologic factors: psychiatric dwelling men and women across the poor physical health (eg, relationship difficulties, depression), United States, using information collected were more likely to neurogenic (eg, spinal cord injury), endo- from in-home interviews.18 This study crine (eg, hyperprolactinemia), arteriogenic found that sexual activity, defined as any say they experience (eg, hypertension, type 2 diabetes mellitus), mutually voluntary sexual contact with sexual problems and drug-induced (eg, antidepressants, another person, declines with age; how- antihypertensives).14 A low testosterone ever, even in the oldest age group (age level also has been associated with potential 75 to 85), 39% of men and 17% of women cognitive changes, decreased bone mineral reported being sexually active in the last density, metabolic syndrome (eg, increased 12 months. Among these persons, 54% risk of type 2 diabetes mellitus), and cardio- reported sexual activity at least 2 times per vascular mortality.10 month; 23% reported having sex at least once a week; and 32% reported engaging Effects