AXIS III and Beyond: Social Function and Sexuality in Late Life

Presenters at this symposium, held at the American Association for Geriatric Psychiatry’s 2003 Annual Meeting, discussed the effects of aging and comorbid illness on sexual health in late life. In addition, they described the current body of knowledge regarding HIV infection, its effects on the brain, and its treatment.

Sexuality and Sexual Health in Older Adults

Individuals aged > 65 years currently comprise about 12% of the US population, and this number is predicted to reach 20% by 2030, reported Tomas L. Griebling, MD, FACS, of the Division of Urologic Surgery and The Center on Aging at The University of Kansas in Kansas City. Despite the growing older population, the issue of sexuality in late life has not been adequately addressed, because of the common perception that older adults lack an interest in sex. Older patients are often reluctant to discuss the topic, and many healthcare providers lack a formal education in sex counseling. Dr. Griebling reviewed various aspects of sexual health in older individuals and described the effects of chronic illnesses and lifestyle issues on sexuality in late life.

Sexual Aspects of Normal Aging
Although libido generally decreases as people age, the interest in sexual activity tends to remain the same. In the Duke Longitudinal Study of Aging, 96% of women and 98% of men aged > 65 years reported that they “like sex.” This continued interest may be the result of an attitudinal change (e.g., no risk of pregnancy in postmenopausal women) or a psychosocial maturation regarding sexuality.

In men, decreased levels of testosterone and increased levels of follicle stimulating hormone affect libido, while in women, relative losses of estrogen and testosterone reduce libido. Men generally exhibit prolonged arousal, plateau, and recovery phases, but their orgasmic function remains relatively unchanged. Women are believed to experience similar phase changes in terms of sexual response and orgasm, but limited data exist regarding sexual function in older women. Dr. Griebling noted that chronic illnesses, present in most older individuals, can affect sexual function.

Effects of Chronic Diseases and Lifestyle on Sexuality
Approximately 80% of individuals aged > 65 years have at least one chronic disease that may affect sexual function, with the most common disorders (diabetes, cardiovascular disease) being the most debilitating (Table 1). Other chronic diseases, such as pelvic vascular disease, atherosclerosis, and arthritis, and the medications used to treat them, also affect sexual response in older adults.

Dr. Griebling explained that sexual problems sometimes may signal other psychosocial disorders, such as depression, delirium, and dementia. Sexuality also is influenced by anxiety concerning partner availability and lifestyle issues. In addition, smoking and alcohol misuse often are associated with sexual problems, particularly erectile dysfunction.

Erectile Dysfunction in Older Men
Approximately 25% of men in their 70s report erectile dysfunction, compared with 55% of men aged > 80 years, and about 600, 000 new cases are diagnosed each year in the United States (Massachusetts Male Aging Study. J Urol. 2000;163:460) (Table 2). Patients presenting with erectile dysfunction should be questioned about smoking habits and comorbid diseases, Dr. Griebling suggested. The therapies for erectile dysfunction include sexual counseling, medications, vacuum erection devices, or implants, depending on the goals of the patient.

Discussion of Sexual History Is Important
Dr. Griebling encourages healthcare providers to discuss these sexual goals and different forms of sexual expression with older patients who are interested in receiving sex counseling. He pointed out that only 1%–3% of older primary care patients will raise the issue of sexual problems, but when the discussion is initiated by the provider, 15%–20% of patients will acknowledge such problems.

Such discussions are becoming increasingly important as more older patients are at risk for sexually transmitted diseases—either through entering non-monogamous relationships or by using professional sex services. Education efforts on preventing transmission of human immunodeficiency virus generally have not targeted older populations, but 10% of AIDS patients are aged > 50 years, of which 30% are individuals aged > 60 years (CDC, 1995). Thus, “healthcare providers must discuss sexual health with older patients because it is increasingly being regarded as a healthcare and quality of life issue,” Dr. Griebling stated. He suggested that healthcare providers discuss general questions regarding sexual function and sexual orientation with all patients, including older adults (Table 3). Such discussions should be conducted in a neutral, supportive atmosphere, and healthcare providers should consider referring patients to colleagues for further evaluation or specialized care.

Finally, Dr. Griebling urged healthcare providers who are not comfortable discussing sexual issues with older adults to seek out further information so that they may be able to evaluate and provide treatment options for patients. “It is important that we encourage the discussion,” he stressed.

Medication Management Among Older Adults in Community Dwellings

“The optimal use of medications in older adults is critical to functional independence,” observed Helen K. Edelberg, MD, MPH, of the Brookdale Department of Geriatrics and Adult Development at Mount Sinai School of Medicine, in New York City. Dr. Edelberg’s presentation focused on polypharmacy and the challenges of medication management in older populations.

Older adults, particularly those recently discharged from hospital, generally take several concomitant medications, including nonprescription drugs. Dr. Edelberg explained that these patients often may not understand how or when to take these drugs. As a result, they may take excessive doses or more medications than are clinically indicated.

Excessive Doses and Overuse of Concomitant Medications
In a study of outpatients, 55% were taking medications that were not indicated, 33% were taking ineffective drugs, and 17% were taking drugs with therapeutic duplications (Schmader, et al. J Am Geriatr Soc. 1994). These problems are not uncommon, Dr. Edelberg observed, and can be complicated by generic versions of drugs or medications obtained from other countries, where the drug names may be different. To minimize such problems, healthcare providers are advised to regularly check the number of medications that a patient is
taking.

The issue of concomitant medications is particularly important, given that the risk of adverse drug effects rises markedly as the number of drugs taken increases. Moreover, most adverse effects are dose related and may be avoided if the dosages are adjusted. However, effective lower doses of many drugs for older populations are not adequately reported (Cohen, et al. Arch Intern Med. 2001). Dr. Edelberg therefore recommended that drug regimens be initiated at the lowest possible level in older adults. She emphasized the need to educate physicians on dosing levels in older patients to avoid inappropriate prescribing.

Inappropriate Prescribing Can Result in Underuse and Overuse of Medications
Dr. Edelberg noted that although inappropriate prescribing is most often associated with overuse of medications, it also can result in their underuse (Lipton, et al. Ann Rev Gerontol Ger. 1992), particularly in patients with depression (Hanlon, et al. 2001).

To avoid inappropriate prescribing, the Beers’ criteria identifies 18 medications or medication classes that physicians should avoid prescribing because they are ineffective or pose an unnecessarily high risk for older patients (Beers, et al. Arch Intern Med. 1997). The criteria also list medications that should be avoided by people with 1 of 14 specific health conditions, because of the likelihood of drug-disease interactions. However, the Beers’ criteria cannot determine whether adverse outcomes will occur and do not identify all cases of inappropriate prescribing, particularly in frail older adults. Moreover, these guidelines need regular updating.

The Medication Appropriateness Index
Another approach to limiting inappropriate prescribing involves the Medication Appropriateness Index (MAI), which considers the effectiveness of the medication, the appropriateness of the dosage, practical directions (can the patient understand how to use the drug?), and correct directions (drug-drug interactions, duration of therapy, therapeutic duplication, and cost) (Hanlon, et al. J Clin Epidemiol. 1992). In a study using the MAI, 75% of 1,644 drugs prescribed for 208 older outpatients were associated with prescribing problems, such as incorrect or impractical directions or use of expensive drugs rather than generic compounds (Schmader, et al).

How to Reduce Common Medication-Related Problems
Medication-related problems in older patients may be attributed to several factors. Older patients frequently consult multiple physicians, and each may prescribe different medications. In addition, older patients may experience atypical adverse effects, such as confusion or incontinence. Further, the risks associated with a drug vary as the patient ages and the risk of discontinuing a medication often is believed to be greater than the benefits.

These problems may be reduced with regular assessment of the patient’s risks (McLeod, et al. Can Med Assoc J. 1997; Vestal, et al. Cancer. 1997) and adverse drug reactions. A “medical manager” should be designated to oversee drug management (Knight, et al. Ann Intern Med. 2001; Chutka, et al. Mayo Clin Proc. 1995) and discontinue medications if necessary. Dr. Edelberg pointed out that motivated patients can successfully discontinue a medication with appropriate education and monitoring (Cormack. Br J Gen Pract. 1994; Graves, et al. Arch Intern Med. 1997; Davidson. Consult Pharm. 1998).

Neuropsychiatry of HIV and AIDS in Later Life

In the United States, 5%–10% of individuals currently infected with human immunodeficiency virus (HIV) are aged Ž 60 years, reported Constantine G. Lyketsos, MD, MHS, Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Co-Director of the Division of Geriatric Psychiatry and Neuropsychiatry, and Director of the Johns Hopkins Comprehensive Alzheimer Program, at The Johns Hopkins Medical Institutions, in Baltimore, Maryland. He noted that the natural course of HIV infection has increased from approximately 10 years to 25–30 years. Thus, acquired immune deficiency syndrome (AIDS) has become a chronic disease and older HIV-infected patients are becoming more common.

Treatment Options for HIV Infection
One of the reasons for the longer natural course of HIV infections is the continuing improvement in HIV therapies. The major classes of antiviral therapy, comprising nucleoside reverse transcriptase inhibitors, non- nucleoside reverse transcriptase inhibitors, and protease inhibitors, can be combined to create the new, high-activity antiretroviral therapy (HART)—a triple therapy that inhibits both reverse transcriptase and protease. These enzymes are critical for viral replication and assembly.

Although antiviral therapy reduces viral loads in the short term, full elimination of HIV is not possible, because the virus hides in host cells. Early initiation of HART can increase CD4 cell counts, but is less effective if the immune system is substantially impaired. Various strains of HIV have different responses to different HART regimens and the complex therapy requires that patients take the medications at precisely timed intervals.

Special Treatment Considerations in Older Populations
Because the HART therapy is very complicated and patient adherence to the regimen is essential, HART is often contraindicated in patients with psychiatric disorders. These patients are believed to be less compliant with therapy. This is particularly relevant to older populations, because AIDS-related psychiatric morbidity increases in older patients. They also may exhibit other illnesses and psychiatric conditions related to older age. Moreover, aging may accelerate progression to AIDS and may increase the incidence of HIV effects on the brain.

Effects of Psychiatric Illnesses on HIV Infection
Patients who are chronically mentally ill, have substance use disorders, or multiple psychiatric diagnoses often engage in at-risk behavior and may exhibit poor adherence to HIV therapy. AIDS progression, in turn, contributes to more
affective disorders and dementia.

A dramatic rise in depressive disturbances has been observed before the onset of clinical symptoms of AIDS. In this disease phase, the immune system generates large amounts of the psychoactive substances interleukin-1 and –6 and tumor necrosis factor. Thus, the increases in depression may be related to fulminant immune dysregulation. In individuals with sexually transmitted disease (but not HIV), depression and post-traumatic stress disorder were the greatest predictors of continued practice of at-risk behaviors for HIV infection, Dr. Lyketsos noted.

Early HIV mania is a bipolar disorder and has symptoms distinct from those of late-onset AIDS mania. Anti-retroviral agents reduce the likelihood of manic episodes in early infection, suggesting that the late-onset mania is caused by brain infection. This mania is less responsive to traditional mood stabilizers and requires neuroleptic treatment.

Managing these psychiatric comorbid conditions tends to improve overall outcomes, Dr. Lyketsos reported. He believes that with the appropriate resources, such as on-site HIV clinics and the availability of specialized psychiatric teams, HIV treatment can be made available to patients with psychiatric conditions.