Sexual Function in the Geriatric Patient
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INTRODUCTION
Individuals age 65 years or older numbered nearly 36 million in 2003. By 2030, this age cohort is expected to double to nearly 72 million persons in the United States.1 While sexual activity may decline with age and sexual dysfunction tends to increase, a survey conducted in 1969 reported that 68% of men and 30% of women over the age of 60 were still sexually active.2 A recent study in Australia found that more than 55% of women over the age of 70 are still interested in sexual activity.3 This highlights the importance of sexuality in older patients and clinicians being aware of issues influencing both normal and impaired sexual functioning in their older patients.
NEUROBIOLOGY OF SEXUAL FUNCTION
The clinician must understand the role of sexual interest and capacity for each individual. Careful questioning when appropriate should allow the patient to review the role of sexual activity during his or her life. For some patients, it will be an essential element in their quality of life. For others, it will be less important. Only the patient can determine this. The presence or absence of a sexual partner is also an important variable to understand. The absence of a sexual partner can be a painful issue that is often ignored by clinicians. Nevertheless, it is helpful for the patient to discuss the pain of such an absence, especially if it is coupled with bereavement issues. The presence of a partner can also be complicated by a significant other having a different level of sexual interest or functional ability than the patient; this can cause problems if such differences foster interpersonal problems. Finally, for some older individuals who have met new partners following the loss of their significant others, sexuality may foster guilt about being “unfaithful” to the deceased. All such issues need to be discussed.
To assess sexual function in patients of all age ranges, the clinician must understand the sexual response cycle, a psychophysiologic cascade of events leading to orgasm. The biological basis of each phase—desire, arousal, and orgasm—should be understood to correlate organic issues with functional problems in each phase. This will enable accurate diagnosis and etiologic assessment of sexual complaints. Divided into three phases (desire, arousal, and orgasm), there is a complex interplay of the endocrine, nervous, and vascular systems4 (Figure).
Sexual desire (libido) is the final result of interacting input from the central and peripheral nervous systems, hormonal action, and psychological factors, both current and remote.5 Initial sexual motivation may occur from sources such as fantasy, visual images, or direct tactile input.6 Testosterone contributes to sexual desire in both men and women, with decreased levels in hypogonadal men and menopausal women that contribute to reduced desire.7 Neither estrogen nor progesterone appears to contribute to sexual desire in either men or women. Nevertheless, estrogen, often utilized in postmenopausal women, may potentiate a sense of “well-being,” as well as modify the effects of estrogen deprivation such as vaginal dryness. Central dopaminergic neurotransmission may also stimulate sexual desire.8 Prolactin acts as a dopamine-inhibiting factor and can suppress libido, which may explain why some psychotropic medications lower sexual desire.
Arousal consists of both the subjective feeling of sexual excitement along with the physiological alterations that occur to foster penile tumescence in men and vaginal lubrication and expansion in women. Sensory afferent impulses from the pudendal nerve reach higher centers of the cerebral cortex (eg, limbic system, interhemispheric region), while vasogenic efferent parasympathetic impulses extend to the corpus cavernosum. Smooth muscle relaxation and vascular engorgement follow input from the parasympathetic nervous system and release of nitric oxide from the vascular endothelium of the penis.
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