Clinical Practice Guidelines for management of sexual disorders in elderly

Abstract

INTRODUCTION Sexuality is an important component of emotional and physical intimacy that most men and women desire to experience throughout their lives. Although it is a fundamental driving force, human sexuality is frequently misunderstood. Even among clinicians who acknowledge the relevance of addressing sexual issues in their patients, there is a general lack of understanding of the optimal approach for sexual problem identification and evaluation. In line with the worldwide trend the number of older adults is notable and is growing in India. The latest data by the Ministry of Statistics and programme implementation in 2016 shows that India has a total of 103.6 million elderly and their population has risen from 5.6% to 8.6% in the last 5 decades, thus this topic which is frequently neglected in the elderly takes on particular importance. Sexual life continues to be important in later life and the elder often view sexuality as an expression of passion, affection, admiration and loyalty. Sexual activity is a means for elder to affirm physical functioning, to maintain a strong sense of identity and establish self-confidence. Studies show that sexual desire does not change with older age and it is important for both men and women. Even in elderly women after menopause, the sexual ability does not completely disappear but it is affected by sexual dysfunction, either in oneself or in the partner. Sexual functioning is a complex combination of bio-psycho-social process which is coordinated by neurological, vascular and endocrine systems and any approach to the study of human sexuality that stresses only in one dimension is counter-productive. Recent studies suggest sexual functioning are influenced by factors representing three domains: biologic (the drive), psychological (the will), social context (the wish), and interactions between them. Sexual function and activity are closely linked with physical health, hence understanding sexual function in the later life course is important from a medical standpoint. Poor sexual function can be due to an underlying serious health condition. For example, it has been found that erectile dysfunction in men may be a marker for asymptomatic coronary artery disease. Diabetes mellitus, which has vascular effects on blood vessels, is one of the most frequent systemic disorders associated with low sexual desire and other sexual problems in aging men whereas diabetic neuropathy can cause impaired sexual desire in women. Understanding the sexual behaviour may uncover protective health effects. Laumann and colleagues discovered an association between sexual well-being and happiness. Numerous prescription drugs have adverse effects on sexual functioning including antidepressants especially SSRI's (causing anorgasmia, erectile dysfunction, decreased libido) and antihypertensives (Diuretics, calcium channel blockers). Moreover adverse drug effects are reported much more frequently in the aging population than in the general population. The use of prescribed medications and the rate of adverse effects of drug therapy are consistently higher in female than male elderly populations and they influence sexual responses including desire by non-specific effects on general well-being, energy levels and mood. Psychological factors (the will) are major determinants of intensity of sexual desire. Psychological factors are independently related to sexual functioning. In addition emotional and interpersonal motivation mediates the effect of sexual drive which is characterized by willingness of person to behave sexually with a given partner and can compensate for diminished physiologic desire of sexual activity (eg as result of declining testosterone levels). Psychological condition such as depression is a risk factor for sexual dysfunction along with the medications associated with treating it. Social context (the wish) also plays a crucial role in sexual function- a role that has been neglected in medical literature. For e.g availability of a partner, intimate communication, relationship duration, characteristics of an individual's sexual partner and cultural experiences. Furthermore, Laumann et al. discovered in their analyses of the Global Study of Sexual Attitudes and Behaviours that association among subjective sexual wellbeing and physical health, mental health, sexual practices, and relationship context were consistent in a broad variety of countries from each major world region. In addition, the authors found that men reported higher levels of subjective sexual well-being regardless of sociocultural context. They also established an overall correlation between subjective sexual well-being and happiness in men and women. Despite the importance of sexual function sexual problems are highly prevalent yet frequently under-recognized and under diagnosed in clinical practice. Adequate attention to these aspects during the history taking will educate the patients regarding the complex nature of sexuality, and prepare them in understanding treatment and outcome realities. The rational selection of therapy by patients is only possible following appropriate education, including information about sexuality and all treatment options for sexual dysfunction. Although not always possible on the first visit, every effort should be made to involve the patient's sexual partner early in the therapeutic process. There are many myths (Table 1) prevailing in the society and the treating physician and collaborating specialist should possess broad knowledge about human sexuality.Table 1: Myths associated with Elderly Sexuality11Psychosocial factors affecting sexuality in Elderly Marriage; For woman availability of a sexually willing, capable and socially sanctioned sexual partner appears to be the most important factor, but problems arise as women usually outlive men. Marital status appears to be less important in men regarding sexual activity. As society is moving from double standards for men and woman these differences are narrowing. More and more older people cohabit to avoid social insecurity; therefore one should not assume older unmarried people are sexually inactive. Extramarital issues should also be kept in mind. Families; Many traditional and joint families, particularly in rural areas fail to provide privacy to the elderly, young newly married occupying the private space. Families who do not accept the sexual needs of divorced or widowed elderly contribute to the negative feelings of the elderly about themselves. Medical and nursing staffs tendency to be judgmental about sexual needs of the elderly patients, gives the impression that this is abnormal. Total care of elderly should encompass addressing sexual feeling and the need for privacy. Remarriage; Remarriage in late life may be even more satisfying than first marriage. Remarriage is often threatening for grown up children who throw storm of protest. Remarriage should be encouraged as loneliness may lead to despair. Sexuality, Education & Awareness; Education usually removes sexual inhibition and unnecessary anxiety, and enhances communication. Only education can give the right attitude regarding sexuality in elderly who are widowed, divorced or cohabiting. Disparity in desire Disparity in desire among couples may increase over years; difficulties arise when one is content with holding hands and the other partner has strong sexual urges. Sexual interest Individuals who enjoyed sex in younger years continue sexual interest when they grow older and remain sexually active in later years. Couples tend to become less inhibited and feel free to explore varying type of sexual stimulation as age advances. Regular sexual expression Regular sexual expression is important, especially for women. Lack of regular sexual expression and privacy correlates with a decrease interest in coitus. Family climacteric; Faulty attitude to “change in life” may affect the couples response if they consider that it implies a change of status and the level of attractiveness, and the sexual activity is inappropriate. Women may suffer from empty nest syndrome or boredom, and have little status of their own. They may have difficulty in re-entering the profession of their own, or picking up the threads of their own lives once their children have left home. Women may link sexual capacity to maternal capacity, and loss of reproductive capacity may be difficult for some to accept, depending on what fertility has meant, and whether they have had as many, too many or too few children compared to what they wanted. Problems faced during pregnancy, infertility and contraception also have an impact. A small number of men over 60 years also experience a syndrome called male climacteric. This is characterized by four or more of the following symptoms; listlessness, weight loss, poor appetite, depressed libido, loss of erectile potency, impaired ability to concentrate, weakness, easy fatigability and irritability. The differentiating and deciding factor is level of testosterone. HORMONES Decrease in testosterone concentrations (normal 270-1100 ng/dl) are noted from the age of 50 years, at the rate of 100 ng/dl per decade and the sensitivity of androgen receptors decreases in men with age; however healthy aging men never become hypogonadal. Testosterone levels in saliva of heterosexual adolescent men correlate positively with the number of times they initiated sexual contact (although whether sexual contact led to the increase in androgens needs to be confirmed). In both men and women, orgasm (induced by masturbation) increases sympathetic activation leading to an increase in heart rate, blood pressure and plasma noradrenaline levels (transiently) an increase in plasma prolactin level for 30 min in men and 60 min in women. In women, sexual arousal increases plasma luteinizing hormone and testosterone levels. The neurohormone oxytocin is also released during orgasm and reinforces pleasure.ILL HEALTHEFFECTS OF AGEING ON SEXUAL RESPONSE CYCLE The capacity to respond to sexual stimulation is effectively retained, although the intensity of physical reaction is slowly reduced in all phases of sexual response cycle. Table 2 mentions the changes in sexual response seen with aging.Table 2: Changes in sexual response with agingSexual Problems: Classification and Epidemiology The ‘Sexual Response Cycle’ was described first by Masters and Johnson in 1966 as the EPOR Model (Excitement, Plateau, Orgasmic and Resolution phases) and later modified by Kaplan in 1974 into the DEOR model (Desire, Excitement, Orgasmic and Resolution phases), which became the accepted model universally. Classically, sexual inadequacy refers to some specific disruption of the ‘Sexual Response Cycle’ (as described by Masters and Johnson in 1970). The clinicians initially faced the difficulty of ascertaining the threshold for sexual disorders. This difficulty was overcome by adopting a patient centered approach. Accordingly, a sexual problem is said to be present when an individual comes with difficulty in particular area of sexual functioning which may or may not be associated with behavioral, mood or cognitive symptoms. As per the DEOR model “Sexual dysfunction is referred to aproblem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity”. Gender identity disorders and paraphilias should be differentiated from sexual inadequacies. ‘Sex’ is most commonly referred to as what an individual is biologically, whereas ‘gender’ is what one becomes in the social context. DSM-5 (Diagnostic and Statistical Manual of Mental Disorders 5th Edition) released in May 2013 defines Sexual Dysfunctions as “a heterogeneous group of disorders that are typically characterized by a clinically significant ‘disturbance in a person's ability to respond sexually or to sexual pleasure” Subtypes can be classified as Lifelong vs acquired and generalized vs situational. Other factors which may influence the symptom presentation include i) Partner's and individual vulnerability factors ii) Relationship issues iii) Psychiatric comorbidity iv) Cultural and v) General medical factors. Common Sexual Problems and Dysfunctions Classification in psychiatry has been a topic of debate and complex area of research. Some are of the opinion that classificatory system creates artificial boundaries between different category of problems; one the best examples for the same is merging of female sexual desire disorders and arousal disorders in DSM-5. Due to its eclectic approach the International classification of mental disorders (ICD-10) has been clinically acceptable in India. The DSM classificatory system by the American Psychiatric Society has been acceptable in academic institutions due to its pointwise approach. DSM 5 highlights the fact that clinical judgement needs to be applied to ascertain whether the sexual dysfunction is due to inadequate stimulation. DSM-5 subtypes include, lifelong which denotes that the problem has been present from the very beginning; acquired denotes that the problem started after a period of normal sexual functioning. Generalized (vs Situational) denotes that the sexual problem is present with all types of stimulation, all situations and partners. Other factors which need to be considered include: 1)Partner factors (sexual problems in the partner),2) Relationship factors, 3) Individual vulnerability factors (poor body image), 4) Cultural or religious factors, 5) Medical factors. 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