Sexuality is a broad term that encompasses sexual identity, activity, attitude toward sex, intimacy, partnership, and pleasure. In this podcast, we cover the basics of sexual function and the effects of aging, medical comorbidities, and mental health on sexuality. We discuss sexual health in long-term care settings and in older adults with cognitive disorders and suggest an approach to commonly encountered sexual health issues. 

Transcript: 

DR JAIN: Sexuality is a broad term that encompasses sexual identity, activity, attitude toward sex, intimacy, partnership, and pleasure. In this podcast, we cover the basics of sexual function and the effects of aging, medical comorbidities, and mental health on sexuality. We discuss sexual health in long-term care settings and in older adults with cognitive disorders and suggest an approach to commonly encountered sexual health issues. 

Welcome to The Carlat Psychiatry Podcast.

This is another episode from the geriatric psychiatry team.

I’m Neha Jain, an Associate professor of psychiatry, Medical Director for the Mood and Anxiety Disorders Program and Associate Program Director for the Geriatric Psychiatry Fellowship Program at the University of Connecticut Health Center, in Farmington, CT. 

In today’s podcast, I am joined by two of my colleagues. 

DR COLLIER: I’m Stephanie Collier, The Editor-in-Chief of The Carlat Geriatric Psychiatry Report. 

DR AZIZ: and I’m Dr. Rehan Aziz, an associate professor of psychiatry and neurology at Hackensack-Meridian School of Medicine. I am also the associate program director for geriatric psychiatry and general psychiatry at Jersey Shore University Medical Center, in Neptune, New Jersey. 

Let's begin our discussion with the topic Dr. Jain started out with. What are your thoughts about how sexual function and sexuality intersect in older adults? 

DR JAIN: Yes, first it is just important to acknowledge that older adults are sexually active because discussions about sexual issues are often avoided in healthcare settings. You know there is often discomfort on part of the patient or clinician, a lack of knowledge-I mean how much training do you remember in Med School and residency about sexual heath-right? Or a fear of embarrassment, or just plain ageist beliefs. However, a fulfilling sex life is a crucial aspect of quality of life for many seniors. 

DR COLLIER: It makes a lot of sense, the question is how do we bring this up when we are talking to our patients and assessing their sexual heath in clinical settings? 

DR JAIN: So, I tend to start first by just asking permission. You know, is it okay if I ask you a few questions about sexual health or sexual activity? Then I ask more open-ended questions, like do you have any concerns or questions do you have in terms of your sexual activity? Or, have you noticed changes in your sexual relationship with your partner over time? Many older adults will not disclose sexual health issues if there are others in the room, so I of try to ensure privacy when screening for sexual dysfunction. I ask about problems with libido, getting/maintaining an erection (for men), dryness or discomfort (for women), and for all genders difficulty achieving orgasm.

DR AZIZ: Dr. Jain I had a question for you regarding that, so my experience is I will usually have patients come to the office.. and if they are accompanied by a patron there is no issue about asking about sexual function/activity, but often they are coming with caregivers or their children. And then it can become quite uncomfortable to ask them these questions. How do you handle those situations? 

DR JAIN: Absolutely, and first of all, I would say don't. You know, so do not ask the question if there is anybody other than the partner, and even sometimes when it is the sexual partner that is present, some people may not feel comfortabl. Usually, I try to sneak in at least some private unites with the patient, and I can just say to whoever is with them, I would like to ask them some questions in private if that is okay with you. And most of the time, the caregiver, whoever is there is completely open to it. Usually, you do not even need to to say why, because there is also other things when you are treating older adults, right, where you want come privacy. So, then I will escort whoever is with them outside, return and talk to the patient.And then bring the family member back in. 

DR. AZIZ: And do you find that patients are forthcoming when you are speaking to them one-on-one? I was reading that only 17% of older adults are asked about their sexual activity. 

DR JAIN: Right, and I think again that number is on us, right? So, we don't ask, but what I have found is that when I ask people are often surprisingly forthcoming and often as the discussion goes on it kind of eases the air and they vbecome more and more open, so usually I like to being it up fairly quickly, so know this is something on the agenda and something this is okay to take about. And usually I find that as they become more comfortable they open up more and more.

​DR COLLER: What kind of questions do you use to open up?

DR JAIN: So, again, do you have any concerns about your sexual activity? You know how is your intimate life with your partner going? And you know kind of gauge their interest/response, sometimes honestly ti seems like they have been waiting for someone to ask that question and they have all these things they feel like are so uncomfortable to talk about and getting that acid permission from the clinician goes such a long way, and if it seems like they are uncomfortable or hesitant I will just kind of back off. And then when I wrap up I will say, do you have any questions or concerns? They will come back to that, so really just bringing questions about sexual health out in the open, acknolegking that it is something that we do discuss in part of a clinical visit, and then sort of following the patients lead. 

DR COLLER: Is there anything you do differently with the older adults when you think go medical comorbidities, things you want to specifically ask about?

DR JAIN: Yes, that is a great question. I specifically, I think we can't ask bout sexual health without asking about medical history. So may of the diseases that older adults deal with: Parkinson's disease, cancer, diabetes, and heart disease can contribute to sexual dysfunction. So, I will usually ask about the underlying medical history. I will also ask if they have noticed any relationship between the two. So if you have sexual dysfunction, do you recall if this happed before/after your diagnosis of X, Y, Z? And then the treatment recommendations usually based on the underlying causes, so you make be prescribing medications such as sildenafil, referring patients to urology or sexual health counseling, or suggesting evaluation for pelvic floor physical therapy for women. 

DR. AZIZ: Do you talk to them about sexually transmitted diseases? I saw that the rates have been increasing of gonorreah and chlamydia in older adults, pretty significantly over the last several years. Which means, they re having sex, we are just not taking them about it.  

DR JAIN: Exactly, and I also think that at some point we sort of assuming that STDs were not going to be as common in older adults. So I always ask if they have any concerns about their or their partners sexual heath, undergoing screening for STDs is pretty common and easy to add it on to the rest of labs. Again, being open-ended, but at the same time being very straightforward, so there is no discomfort in bringing up concerns, and if they have additional concerns then they don't feel uncomfortable bringing those up. I do, you know, want to emphasize, because I have certainly been guilty of this, trying to avoid making assumptions about sexual orientation, or relationship status. And again following their lead, allowing them to disclose their preferences, at their own pace.

DR COLLIER: It almost sounds like when you ask about bowel habits, for example, if you are feeling comfortable asking the question the patients feels more comfortable answering the questions. If you feel uncomfortable asking the questions, they will feel a little bit more embarrassed. So, asking in a very straightforward way- that's great advice. 

DR JAIN: And you know, we ask about invasive things all the time. You know, you're asking someone about their bowel habits is just as invasive as asking someone about their sexual health. So, I think to a big extent it's our won discomfort that plays into this. 

DR AZIZ: We know that depression and anxiety are important risk factors for sexual dysfunction, as are the medications used to treat them. SSRIs can cause hypoactive sexual desire, erectile dysfunction, and delayed ejaculation. 

So, when we have a patient that has sexual dysfunction and depression, or anxiety, how do you suggest we tailor our treatment and how duo we discuss these possible sides effects with them?

DR JAIN: Yes, Dr. Aziz. So I think again, I think first of all being aware that some sexual side effects are just as much a risk for older adults as they are for younger adults. Before prescribing antidepressants and during the first few follow-ups after starting a new anti-depressant, I regularly discuss potential sexual side effects. Again, just with everything else, you know, stomach discomfort, headaches, insomnia-sexual side effects. These side effects may be influenced by the dosage and can sometimes persist even after discontinuing the medication. I tend to suggest taking a brief drug holidays quite a bit. So if you have planned sexual activity, you know, don't take your medication for 24-48 hours but in some cases where this is a persistent problem, recommend switching to antidepressants that are less likely to cause sexual side effects, like bupropion, mirtazapine, or vortioxetine. Do you have any other approached that might work in such a situation?

DR COLLIER: Sometimes I also think about augmenting with bupropion, and I am curious what your thoughts are about that?

DR JAIN: So, I personally, you know, I have read that approach. I just personally have not had much luck with it. I don't know what you think Rehan?

DR AZIZ: I think I have had fair success with it. I will usually switch to bupropion, if clinically indicated, but also augmenting with bupropion seems like a fair strategy. If it is an older adult that is sexually active, and that is a concern for them, usually I will start with mirtazapine or bupropion from the beginning. And as you indicated there has been more data that vortioxetine may also be beneficial for having lover rates for sexual dysfunction that SSRIs. Question for you, my worry with the drug holidays is that it will become a permeant holiday. Have you seen that happen?

DR JAIN: Interestingly, less than I would have thought. An, you know, drug compliance rates are in general not very good. People don't take medications everyday, despite what we like to think, so the people who come in complaining of sexual side effects and thinking about, what can I do to fix this? Generally seem to be somewhat more motivated, and often the sexual side effects are often if not entirely the reason behind the noncompliance. So if we can address that with the drug holiday, I think it actually makes them more likely to resume the medication. I am not above reminding people though, or cheering in on them "okay, how many days were you actually off it before you restarted?"And then sort of rendering those permitters. 

DR COLLIER: We talked about antidepressants, what about the antipsychotics? So we know that antipsychotics can also have negative effects on sexuality, reduced libido, causing erectile dysfunction and amenorrhea in younger adults. The sexual side effects are greater in first-generation and prolactin-inducing antipsychotics like risperidone and paliperidone. Dr. Jain, what is your process for addressing antipsychotics and sexual dysfunction? 

DR JAIN: Thats a great question, because again, when we think of sexual dysfunction we tend to think of antidepressants more than antipsychotics. But the same idea, before prescribing and during the first few follow-up visits after starting an antipsychotic, I will ask about any sexual side effects. In generally, the indications for antipsychotics are such that I don't usually recommend a drug holiday, however, if sexual side effects are present, I may suggest a switch to aripiprazole, which tends to have fewer sexual side effects. There are some newer antipsychotics out on the market now with similar profiles. Or recommending the use of adjuvant sildenafil to manage the dysfunction. 

DR AZIZ: It is well-known that sexual dysfunction can be affected by the aging process. As an example, women tend to have lower estrogen levels after menopause, which can lead to vulvovaginal atrophy and discomfort during sexual activity. Dr. Jain or Dr. Collier, how do you address this? 

DR JAIN: Again, a very common problem Rehan, and one that we doing ask about often I think. So always ask. If it is an issue of dryness or discomfort during sex, the first recommendation is usually to use a vaginal lubricant. I do encourage women to talk to their primary care physician or their gynecologist about possible treatment options as well, including local and systemic hormone therapy. For older men who are experiencing erectile and ejaculatory dysfunction, again emphasizing hat its very common, and then looking at modifiable risk factors like obesity, smoking, or hypertension. Additionally, I might suggest psychotherapy or a trial of a phosphodiesterase-5 inhibitor. 

DR COLLIER: This is another one of those topics that may not come up unless you ask about it, normalize it too. So I have found to day that it is helpful sometimes to say many of my patients experience this. Is this an issue for you as well? 

DR JAIN: Yes, and the other piece, is- I don't know if you have both seen this- is menopause can vary so widely among women. So, you know, anywhere from women who have premature menopause to in their 40s all the way to earn they are in late 50s. So this question has a very long life, you know, so we need to be asking it across the lifespan almost.

DR AZIZ: Let's talk about treating inappropriate sexual behavior in dementia, it can be challenging for some clinicians. It can be very complicated if it happens in a long-term care setting or another community setting. How do you all approach it? 

DR COLLIER: Dr. Aziz, that is an excellent question and it also effects the family members. A significant concern. Different dementias can cause inappropriate sexual behavior. Alzheimer's dementia often causes a lack of interest in sexual activity, but it can also contribute to inappropriate behaviors. Frontotemporal dementia can lead to early sexual disinhibition, while other dementias may have it in later stages this could appear pretty early on. And then the effectiveness of psychotropic drugs for addressing inappropriate sexual behaviors is a little bit uncertain.The best of course is behavioral interventions. But what do they look like in practice Redirecting, distracting, reminding, they can be useful. But sometimes we have to think a little bit harder about what can stop these behaviors. Some clinicians do use jumpsuits or they button the shirt on backwards, so that the buttons are in the back so that way they don't expose themselves. But of course this is something where a clinician really needs to weigh the risks and benefits before suggesting something like that. 

DR AZIZ: Those are really interesting ideas. I think one thing to consider also is that patients may misinterpret behavior. So if personal care is being provided by a nurse or home health aid, they may experience that as a more intimate gesture or touch than it is meant to be and so there may be ways for a care giver to alter what they are doing or to redirect the patient. Dr. Jain how do you treat inappropriate sexual behavior? I mean luckily they are not that common, but when it happens, especially in a long term care setting it can be very upsetting for the staff and for family. 

DR JAIN: Yes, and it's one of those things where for us its just one of the many behaviors, unfortunately that can come with dementia, but it has a disproportionate effect in terms of distress for patients, for families, for caregivers. If behavioral interventions are not working there are case studies that suggest the use of antidepressants, particularly SSRIs, as well as antipsychotics. There is less evidence for the effectiveness of mood stabilizers, antihypertensives, and cimetidine. I have always struggles, you know, when though the option of using anti-androgens is there, I have always struggled with the ethical concerns with that, especially if the patients can not provide informed consent. So I wonder what your thought are about that?

DR AZIZ: I think that's really complicated. So, I have never started an anti-androgen, but I have continued them. And these were patients who were in long-term care settings, so for me the decision process was that; well if they are not on it, they will have inappropriate behavior and they are going to be asked to leave the facility. So they re going to be in a worse situation because they will have no place to stay and no one providing care, and it was the only way to manage their very very aggressive and disturbing behavior. So it was with a heavy heart that I continued the anti-androgens; but I agree with you they are always a very very last resort choice. 

DR COLLIER: And I have had some success with the SSRI approach. Where inappropriate behavior absolutely stoped once a patient was at a high enough dose. So for tolerability and as you mentioned sort of the risk benefit ration, you should minimize the SSRIs and pushing the doe up hight enough to stop the inappropriate behaviors which can absolutely disappear. 

DR JAIN: That's a good point. Do you feel like you needed to use higher than usual doses? Or maybe even other does to achieve that effect with SSRIs?

DR COLLIER: No, but it was going towards the higher FDA approved maximum range actually. Which generally, when we think about treating older adults they often benefit at lower does, but in terms of the sexual behavior I think it is dose dependent. 

DR AZIZ: How long did it take your patients to respond? 

DR COLLIER: This is a small number of patients that I am spreaking about, but it was a couple weeks. 

DR AZIZ: Okay, so we have to be patient.

DR COLLIER: This happed actually in the inpatient setting where it was first noticed, so it was in an inpatient stay where as the dose increased the behaviors went down. And that was the only variable at the time. 

DR JAIN: Yes, I think that is the big thing with SSRIs, is with just the delay in repose you start something you titrate the dose and then there is just a lot of education with staff and family while we wait for the medications to kick in. I am curious abut sort of the ethical/legal aspect of this in terms of documentation, if you have any thoughts, in terms of who do you involve, especially if the patient does not have capacity. How do you make sure that this is in line with the current regulations and how do you document it all?

DR COLLIER: I don't think the documentation would be particularly different here because you are still asking for informed consent, you are still going through the informed consent procedure and it the patient is not able to provide informed consent than it is a discussion the moves to the healthcare proxy or whoever is making decisions for the patient. So our documentation does not have to be extensive it can can be quite brief with the precautions of informed consent. Whether its treatments of inappropriate behaviors or other behavior where you are thinking of something. Say like an antipsychotic of a patient with dementia.

DR AZIZ: I think I would add to that when we are using anti-androgens, just to be clear it is a form of chemical castrations o it is a difficult decision to make. But as I said its sometimes necessary ignorer for a patient to receive the care that they need. If a patient is hospitalized there is also the option to consult a bioethics committee for a second opinion, they can often be very helpful in looking at the case from an alternate point of view.

DR JAIN: Yes, and I recall doing that when we were inpatient. What I have also done in the outpacing setting sometimes, if you don't have access to a bioethics committee, is in addition to family, involving another physician that's includied in the patients care. Often its there primary care doctor, family doctor, staff at the facility that they are residing. But again making sure that it is an informed decision and everyone is comfortable with it. 

DR COLLIER: Dr. Jain that is an excellent suggestion. 

We talked a little bit about the limitations in terms of medications and providing quality care to patients experience sexual disfunction. I think we can also focus on long term care settings, and let's discuss a little bit how this setting itself can hinder healthy expression of sexuality in older adults. 

DR AZIZ: So it's a significant issue in long term care settings. Multiple obstacles can prevent healthy sexual expression in those settings, including as staff bias (i.e., labeling such behaviors as "inappropriate"), insufficient privacy, the practice of separating couples upon admission to long- term care, concerns regarding consent and capacity, and lastly there can be discrimination against LGBTQ individuals. And for many of them it can be reason that they may avoid placement into long term care facilities. 

DR JAIN: I agree, and this is a topic that I feel very strongly about. And I think that as a clinician community we sort of want to lead the charge to avoid or reduce these restrictions. So providing risk and capacity assessment training as early as possible, staff can feels more confidence creating a safe environment for residence and in managing sexual behaviors and allowing residents to express their sexuality. Making simple changes to the environment, like offering Do Not Disturb signs or offering private spaces. Again you know, its a way without necessarily making it very obvious, just allowing people to feel more comfortable and feel okay with the idea of continuing to express their sexuality, even when they are not home anymore. But I don't think this often completely fixes the restrictions that you mentioned Dr. Aziz. I think traditionally or historically there has just been so much bias against sexual activity in facilities that its a cultural shift that is sort of slow incoming.I wonder what you experience has been Dr. Colllier?

DR COLLIER: I think with everything change takes time, and I think that even with our best intentions, education does not really change the process or the outcomes necessarily. There is more that needs to be done on multiple levels, and as a clinician you can feel a little bit trapped; where dipole your best efforts you are not ensuring the optimal care for the patients in long term settings

DR JAIN: I have certainly been in those situations where all you can do is provide empathy and validation to the patient and really acknowledge their distress. There is also the high levels of discrimination that LGBTQ patients tend to face in long term care settings, and the stigma is often so internalized by older adults so they are hesitant to discuss sexuality. And as Rehan said, more likely to avoid long term care settings because ion that stigma. You know staff training/staff education I think even creating concrete policies where possible so that the system can adapt and become a route part of training. When we have team meetings and discussions avoiding sexual preferences and using more inclusive language when asking open-ended questions. And I think this is certainly where the older generation of clinician, of which I now include myself, has had to learn things and I think we continue to do that with each successive wave of clinicians. Connecting older LGBTQ adults to community resources, such as www.sageusa.org, which is the Services and Advocacy for LGBT Elders USA. Those are all things owe can of in out program; somebody put together a resource guide for LGBTQ older adults and it was interesting that nobody realized the need for it, but as soon as it was created it was distributed so widely because the need was there, we just never realized it.

DR AZIZ: That sounds like an incredible document. Is that publicly available Dr. Jain?

DR JAIN: I don't think it is but I don't know why it could not be, so I will find that out for you.

I think that it's very important for us to acknowledge that sexuality remains a significant aspect of life for older adults, with or without sexual dysfunction; and we can help our patients by asking about there sexual health, by addressing their sexual dysfunction, by creating more education and more safety around this discussion. Treatment options like behavioral interventions, psychotherapy, and medications, those should all be considered and molded to the needs of each individual patient. 

DR COLLIER: The newsletter clinical update is available for subscribers to read in The Carlat Geriatric Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

DR AZIZ: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

DR JAIN: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

DR COLLIER: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.

As always, thanks for listening and have a great day!