Sexuality and sexual function are important
indicators of quality of life in all stages of adulthood. Regardless of age,
every individual harbors the need for intimacy, physical affection, and
sexuality. Despite this basic fact, many studies on sexuality have ignored the
attitudes and behaviors of older adults, focusing instead on those adults in
their reproductive years.1
Data show that more than 50% of Americans older
than 60 engage in sexual activity at least on a monthly basis. Among those 80
and older, more than 25% report regular sexual activity.2 While the
number of people who would engage in sexual activity but are unable (e.g., due
to organic disease or lack of opportunity) is not known, existing rates
clearly demonstrate that patients maintain an interest in sex well into their
Pharmacists, without realizing it, may harbor
prejudiced attitudes about the sexuality of the senior citizens for whom they
provide care. They may be embarrassed to discuss sexual habits with seniors or
feel that these issues are not important to older patients. As front-line
health care providers, pharmacists must increase their awareness of the
important role sexuality has in the overall well-being of adults at all ages.
This article focuses on drug therapies available to optimize the sexual
well-being of senior citizens and the possible role of the pharmacist in
improving this vital area of quality of life.
Effects of Aging on Sexuality
Both men and women experience gender-specific influences on sexuality that
will be discussed separately. Gender-neutral effects on sexuality in seniors
include depression, coronary disease, vascular disease (e.g., angina,
diabetes), mobility and flexibility issues, lack of socializing opportunities,
loss of life partners, and, perhaps most important to pharmacists, the
increased use of OTC and prescription medications in this age-group.3
Common classes of medications that can cause sexual dysfunction in seniors
are included in Table 1.
Assessing the Senior Patient
The first step in optimizing the
sexual well-being of seniors is to incorporate the topic into the basic health
care assessment. Pharmacists should not be shy about broaching the subject
with seniors and should listen attentively to their responses. The discussion
should include physical sexual function, an evaluation of high-risk sexual
habits, and an overview of the patient's beliefs regarding sexuality.
High-Risk Sexual Behaviors
Cardiovascular health is an
important consideration when planning to improve sexual dysfunction in
seniors. Patients who have abandoned sexual activity due to dysfunction may
not be prepared for the cardiac stress that may follow improved sexual
function. Pharmacists should be especially aware of patients with preexisting
angina, as sexual activity is an important trigger for anginal episodes. In
addition, patients with angina may have been prescribed nitrate therapies,
contraindicating the concurrent use of phosphodiesterase type 5 (PDE-5)
inhibitors, designed to treat erectile dysfunction.
Sexually transmitted diseases (STDs) are much more
commonly diagnosed among those younger than 50, but the risk of STDs among
seniors should not be discounted. Long-term diseases such as genital herpes
and untreated syphilis are the most common STDs in older adults.4
Discussion of safe sex practices, such as the use of latex condoms, is even
more important if the patient is resuming sexual activity after the loss of a
lifelong monogamous partner. Patients in such a situation may be naïve about
the need for and the techniques of safe sex.1 STDs are also a key
indicator in the possibility of sexual assault in nursing home patients. It
may be an especially important clue if a nursing home resident with diminished
mental capacity presents with an STD.4
When evaluating sexual
dysfunction in patients, it is important to obtain a complete social, sexual,
and medical history. Ideally, the patient's significant other should be
involved with this assessment to determine which therapy would be most
appropriate and acceptable for the patient and their relationship. A
comprehensive physical examination with laboratory screening is appropriately
performed by the patient's physician (Table 2). The patient's primary
care provider often makes a diagnosis without a comprehensive work-up; thus,
an underlying pathology may be overlooked.
Sexual Dysfunction in Senior Men
Sexual dysfunction can affect men
of any age; however, it is more prevalent with advancing age and
comorbidities. By the end of 2025, erectile dysfunction is proposed to affect
more than 300 million men.5 Understanding possible etiologies and
available pharmacotherapuetic options, in addition to the individual patient's
situation, allows providers to optimize treatment approaches.
The origin of sexual dysfunction may be organic,
psychogenic, or "mixed" in nature. Organic causes may be pharmacologic,
hormonal, neurologic, or vascular (Table 1). Improving a current
disease state may result in decreased problems of sexual dysfunction. However,
this dysfunction may not be reversible. According to one study, midlife
changes involving smoking cessation, weight loss, and reduced alcohol
consumption may not improve or correct sexual dysfunction.6 The
term sexual dysfunctionincludes problems with libido, ejaculation,
erectile function, or a combination of these factors. Decreased libido is
often present in patients with hypotestosteronemia or hyperprolactinemia or
psychogenic causes. Retrograde ejaculation is a disorder more frequent in
older men, especially among patients who undergo prostate resection or have
neurogenic disorders. Erectile dysfunction is the most common sexual
dysfunction and is defined as failure to achieve and/or maintain an erection
of sufficient duration and rigidity to satisfy intercourse through vaginal
penetration in more than 25% of sexual attempts.7
Oral Therapies for Erectile Dysfunction:
PDE-5 inhibitors have revolutionized
therapy for erectile dysfunction. The three products available are sildenafil
citrate (Viagra), vardenafil HCl (Levitra), and tadalafil (Cialis) (Table 3
). These medications require sexual arousal for success. During sexual
arousal, nitric oxide and increased levels of cyclic guanosine monophosphate
(cGMP) cause dilation within the vasculature of the corpus cavernosum. PDE-5
is an enzyme that breaks down cGMP. PDE-5 inhibitors delay the degradation of
cGMP and allow the patient to attain and maintain a satisfactory erection.
Structurally, tadalafil varies from sildenafil and vardenafil; thus, there are
differences in their pharmacokinetic profiles.8-10 Prescribing
information recommends that patients take tadalafil 25 to 60 minutes prior to
sexual activities.11-13 However, numerous studies have demonstrated
successful erections within 20 minutes after ingesting tadalafil.14-16
Tadalafil has an advantage for patient spontaneity due to its long half-life.
Rates of absorption for sildenafil and vardenafil are affected if taken with
food, resulting in delayed absorption. If food is taken with these
medications, a low-fat meal is recommended.
Therapy discontinuation may be due to lack of
efficacy; however, tolerability is often an issue. Most side effects can be
attributed to the vasodilatory effects at various parts of the body. There are
11 identified PDE isozymes. Although the PDE-5 inhibitors are potent and
selective for the PDE-5 isozyme, they also display specificities for other PDE
isozymes. Both sildenafil and vardenafil provide inhibition of PDE-6 isolated
in the retina, causing difficulty of light transfer through nerve impulse.
Vision abnormalities are limited and not well documented with tadalafil due to
its specificity of PDE-5 isozyme over PDE-6 isozyme (>700 times).17,18
It is difficult to compare PDE-5 inhibitors due to
varying study designs and inconsistent evaluation of satisfaction and previous
failure resulting from erectile dysfunction. After education, the patient will
hold the ultimate decision as to which PDE-5 inhibitor may be best suited for
his needs and lifestyle. It is important to remember that not all patients
with erectile dysfunction are immediate candidates for PDE-5 inhibitors (
Apomorphine is a central-acting dopamine receptor
agonist that enhances activation of the neurons during sexual stimulation.
Efficacy rates of successful erections range from 48% to 55%. Yet, in a
crossover study comparing apomorphine to sildenafil, success rates were far
superior with sildenafil (35% vs. 75%, respectively).18,19
Apomorphine appears to be an excellent first-line agent for patients who have
contraindications to PDE-5 inhibitors, but the sublingual formation is not
available in the United States.
Although nitroglycerin paste applied directly to
the penis has been shown to increase rigidity, absorption into the female
partner caused headaches.7 Alprostadil (prostaglandin E1
) can be administered as an intracavernosal injection or by
intraurethral suppositories. Complications consist of penile pain, prolonged
erection, priapism, and fibrosis.18 Intraurethral pellets of
alprostadil were marketed as an alternative to intracavernosal injections. Due
to absorption issues, higher doses of alprostadil are necessary by
Mechanical devices and penile prostheses may be an
option for patients who are not candidates for these therapies. Since the
placement of penile implants requires the removal of some or all erectile
tissue, this treatment option is irreversible. Therefore, most providers will
offer penile implants as a last-line therapy.
Sexual Dysfunction in Senior Women
Following menopause, many women
experience physiologic changes that negatively impact their sexual health,
and, as a result, nearly half of postmenopausal women are affected by some
degree of sexual dysfunction.3 Common changes due to estrogen
deprivation of the postmenopausal state include vaginal dryness, reduced
vaginal elasticity and muscle tone, uterine atrophy, decreased size and
sensitivity of the clitoris, and bladder insufficiency and/or
intercourse-related urinary incontinence. These factors may contribute to
decreased arousal, uncomfortable or painful intercourse (dyspareunia),
embarrassment issues, and/or the inability to achieve an orgasm (anorgasmia).
An unfortunate disparity between genders is that
some cultures are less accepting of sexuality in senior women than in senior
men. In patriarchal societies (i.e., Asian, Latin, Native American), it has
been reported that a woman's sexual urges are expected to decline after
menopause, as she is no longer able to reproduce. Many cultures also
discourage sexuality among widowed women, while this type of restriction is
not imposed upon men who lose their wives. Pharmacists must be sensitive to
these cultural issues but should not neglect a senior woman who wishes to
continue to be sexually active despite the views of her cultural community.
Another gender-based disparity is that due to
their longer average lifespan, women tend to suffer more than men from a lack
of available sex partners later in life. Thus, older women may experience
sexual dysfunction not from disability or disease but from lack of
Drug Therapies for Women:
The use of PDE-5 inhibitors, effective in treating erectile dysfunction in
men, is much more controversial in treating sexual dysfunction in women. The
use of sildenafil has been shown to improve localized genital blood flow in
postmenopausal women, but this has often not translated into perceived
improvements in sexual function or the ability to achieve orgasm.20
The dopamine agonist apomorphine may also help
women suffering from sexual dysfunction; however, the benefits of this agent
have been demonstrated primarily in premenopausal women. In one small trial,
it was shown to mildly improve the symptoms of hypoactive sexual desire and
sexual arousal disorder.21
Often, the only therapy needed to significantly
improve postmenopausal dyspareunia is the use of vaginal lubricants during
intercourse. Water-based lubricants such as Astroglide or K-Y Jelly should be
recommended to women who follow safe-sex practices by having their male
partner(s) use latex condoms. The addition of estrogen-containing vaginal
creams may also be of benefit; they not only correct vaginal dryness, but also
reverse some genitourinary effects associated with postmenopausal estrogen
deficiency. Women should be counseled that these creams are not appropriate
for use as lubricants during intercourse, as sexual activity may displace the
medication, but are most appropriately used overnight.
Sexual health is important to
patients of all ages but may be mistakenly overlooked by pharmacists when
dealing with older patients. Pharmacists have an important role in supporting
the quality of life in senior patients by being open to discussions on sexual
health and recommending appropriate medications and nondrug therapies that may
improve patients' sexual function.
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