SPECIAL ISSUES IN AGING
From the West Coast Geriatric Conference, presented March 7-10, 2007, by the University of California, San Diego,
School of Medicine
| ALCOHOL AND OLDER ADULTS —Tamara L. Wall, PhD, Assistant Professor, Department of Psychiatry, University
of California, San Diego, School of Medicine, and Associate Chief, Psychology Service, Veterans Affairs San Diego
Healthcare System
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| Alcohol use in older adults: most people decrease consumption over time, but in those who do not, more neurocognitive
and physiologic complications seen than in younger patients; among most common problems in elderly are interactions
between alcohol and medications; at least 100 prescription and nonprescription medications known to interact
adversely with alcohol
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| Alcohol problems among older adults: older people generally consume lower quantity of alcohol each day, but as
few as 2 drinks per day can cause neurocognitive and other problems in older individuals; in older people, variety of
health-related problems (and hospitalizations) associated with alcohol (red flags include frequent falls, trauma, hypertension,
macrocytosis, peripheral neuropathy, depression, insomnia, loss of libido, late-onset seizure disorder, confusion,
poor nutrition, incontinence, diarrhea, myopathy, inadequate self-care, and adverse reactions to medications); older
adults who use alcohol more likely to smoke tobacco (however, these people more likely to die from tobacco-related
problems than from alcohol-related problems)
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| Clinical course among older adults: precipitous drop in alcohol intake seen in people >75 yr of age, and believed to
be due to increase in health problems and increase in number of women >75 yr of age (throughout lifespan, women
less likely than men to drink alcohol and to meet criteria for alcohol use disorder)
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 | Early-onset (<60 yr of age) vs late-onset alcohol-use disorder: early onset accounts for ≈67% of older alcoholics, who
tend to be heavier drinkers, to have more severe alcohol-related problems, and to carry greater genetic risk or have
family history of alcoholism; late onset accounts for ≈33% of older alcoholics; women more likely than men to have
late-onset alcohol-use disorder; factors that may precipitate late-onset alcohol-use disorder include retirement, not having
other reinforcing activities in life, living alone, death of spouse, and increasing medical or psychiatric problems; individuals
with alcohol use disorders die 10 to 15 yr prematurely; leading causes of death include accidents, suicide,
heart disease, infections, chronic liver disease and cirrhosis, pancreatitis, and cancer; in addition, in individuals >60 yr
of age, alcohol impairs neuropsychologic functioning, compromising relationships, social support systems, and coping
resources
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| Older adults with alcohol use disorders: depression common, and course protracted; study found that alcohol increases
risk for psychotic symptoms in older adults 8-fold in men and 3-fold in women; neurocognitive deficits known to
be caused by alcohol dependence include deficits in sustained attention, abstract reasoning, perceptual motor skills, and
short-term memory; Italian study found that low to moderate doses of alcohol may improve neurocognitive functioning,
and impairments occur only when consumption >40 g/day for women and >80 g/day for men; increased risk of alcohol
use and dependence seen in people with dementia
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| Underestimation of alcohol problems in older adults: medical problems, neurocognitive impairment, and psychiatric
disorders common in older people with alcohol-use disorders, but often seen inappropriately as part of normal aging
process; older adults less likely to be screened for alcohol-related problems and less likely to be treated
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| Assessment of alcohol use: speaker recommends asking about alcohol use every time prescription written; ask direct
questions, such as, “how often do you drink?” and “do you ever have more than 1 drink per day?” state markers that can
indicate heavy alcohol use include elevated γ-glutamyltransferase (GGT) and mean corpuscular volume (MCV); toxicology
screen may be helpful; of screening questionnaires, only Michigan Alcohol Screening Test G (MAST-G) specific for
geriatric populations; most common screening questionnaire probably CAGE (have you ever felt need to cut down on
your drinking? have you ever felt annoyed by someone’s criticizing your drinking? have you ever felt guilty about your
drinking? have you ever had a drink first thing in the morning [eye-opener]?); speaker recommends Alcohol Use Disorder
Identification Test (AUDIT), developed by World Health Organization for use in primary care settings and which has
high degree of sensitivity and specificity
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| Brief intervention: shown that 30% of people cut back on alcohol consumption in response to brief intervention by
health care professional; present screening information in objective and nonconfrontational manner; asking about benefits
(instead of disadvantages) of alcohol use can be disarming and lead to greater insight into patient’s motive for using
alcohol; provide direct feedback, such as, “I think that your medical problems are being complicated by your alcohol consumption
and that you should not have more than 1 drink per day”; ask whether patient understands that information and
whether he or she is willing to comply; behavior-modification techniques can be helpful; studies show advantage to follow-up
phone calls and visits; educate patient about myths (eg, alcohol improves sleep, mood, or sexual performance) associated
with alcohol
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| Treatment: once alcohol abuse or dependence identified in older person, treatment essentially same as in younger person,
with caveat that older person may require hospitalization for detoxification if he or she has other medical conditions
that would be exacerbated by withdrawal; for inpatient or outpatient treatment, focus on motivating patient and on eliminating
barriers to treatment; follow-up useful in helping patient to maintain abstinence and to improve quality of life
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| Summary: health care providers in strategic position to detect alcohol-related problems in older people; older individuals
vulnerable to medical and psychiatric complications of alcohol use; variety of clinical tools available to help identify alcohol-related
problems; brief interventions, as well as treatment, efficacious
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| SEXUALITY, AGING, AND DEMENTIA —Daniel D. Sewell, MD, Associate Clinical Professor of Psychiatry, University
of California, San Diego, School of Medicine
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| Sexual activity in later life: often subject of humor or avoidance in discussion; myths—older people not interested in
sex; older people do not need education or information about sex; people who are ill or dying are not interested in sex;
sex may be harmful to people who are sick or dying; reality—sex, like thirst, hunger, and pain avoidance, is biological
drive “hard wired in each of us”; in traditional societies, sex among older people or between older and younger persons
considered normal and socially acceptable
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| Reasons for sex in older individuals: continuation of biological imperative; facilitation of instruction and enhanced
survival of relationships between people of differing ages; affirmation and continual redefinition of relationship and of
self; stress reduction; helps maintain good physical health; fun
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| Sexuality in Western societies: studies and surveys show interest in sex continues into old age; in survey, of people
45 to 59 yr of age, 78% of women and 84% of men reported having steady sex partner; among those >75 yr of age, 21%
of women and 58% of men had steady sex partner; other findings were that individuals >60 yr of age less likely to approve
of oral sex, masturbation, and sex outside of marriage; in study, one third of women and two thirds of men >80 yr
of age reported that they were sexually active; 64% of women and 83% of men engage in noncoital physical intimacy at
least sometimes, and 39% of women and 66% of men reported having sexual experiences at least several times per
month; conclusions—older men possibly more sexually active than older women; many older people have positive sexual
experiences but do not include coitus as part of those experiences; level of sexual activity in youth predicts level of
sexual activity as people age; women who perceived themselves as overall healthy most likely to report their physical intimacy
as satisfying; men who perceived themselves as overall healthy most likely to report their sexual experiences as
satisfying, but did not comment on “intimacy”
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| Intimacy: one-sided intimacy occurs when one person talks and another listens; two-sided intimacy requires both people
to talk and to listen; women believe two-sided intimacy essential for quality sexual experiences; intimacy involves issues
of safety, comfort, and attraction; feeling secure and positive about relationship and positive self-image (including feeling
comfortable with own body and with own sexuality) important; adequate general communication and adequate communication
about sex in particular important to physical intimacy
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| Reality: sexuality continues in later life, although frequency of sexual activity may decline; biologic changes of aging result
in slowing of sexual response; however, individuals’ description of enjoyment and of importance of sex remain high;
meaning and significance of sex remains important no matter how old person becomes
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| Sexual dysfunction: not normal part of aging, but rather results from pathologic aging; regardless of age, sexual dysfunction
in most cases can be successfully treated
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| Guidelines for discussing sexual issues with patients: establish rapport; consider postponing subject until after
first visit; introduce topic by putting it in context (such as explaining that sex is biologic drive) and that it can be sign
of health and activity that helps maintain health; accept that health care provider may be uncomfortable with subject
initially, but comfort will increase with practice; patients are sensitive to clues therapist sends, may think therapist is
unwilling to discuss topic; do not wait for patient or partner to introduce topic of sexuality; if one person has dementia,
his or her partner may think it wrong to discuss or engage in sex
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| Taking the plunge: begin with neutral question, like “have you experienced any changes in your sex life?” do not assume
sexual activities involve coitus, but ask about sexual activities couple practice; use open-ended questions; allow sufficient
time for couple to answer (as people age, they tend to process information more slowly; allow both partners time
to comprehend question and to formulate answer); determine couple’s desire for sexual intimacy; be open to wide
range of behaviors that express sexual intimacy; explore couple’s social, cultural, and psychologic perceptions of sexuality;
review of medical history and medications may reveal sexual dysfunction
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| Avoid assumptions: that couple is heterosexual or homosexual (study showed that <10% of older people asked about
their sexual orientation; ask); be clear that sexual activity includes coital and noncoital behaviors
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| HIV infection: in United States, 5% to 6% of people diagnosed with HIV infection each year >55 yr of age; use of condoms
lower among people >50 yr of age (study found that only 5% of older men use condoms; emphasize that condoms
not only provide contraception, but also help prevent transmission of sexually transmitted diseases)
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| Research findings: in study of 55 men with Alzheimer’s disease, 62% developed erectile dysfunction “around the same
time of the onset of their dementia”; this impotence unrelated to age, degree of cognitive impairment, presence of depression,
medications, or physical problems; spouses often reported that partner with dementia showed decrease in
sexual desire, but pattern varied considerably from one couple to another; in some couples, partner with dementia may
experience increased sexual desire or may begin to make out-of-the-ordinary demands, which may be a reflection of
personality changes that accompany dementia that affects primarily frontal lobes
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| Sexuality and dementia: “in the absence of a cure [for dementia] ... the most significant thing [health care providers]
can do is adapt our approaches with each change in symptoms to make life as meaningful and satisfying as possible”; dementia
does not necessarily rob person of biologic drive for sex; speaker opines that dementia also does not rob person of
need to have affirmation of his or her attractiveness or of his or her need to have sense of self; just as in person without
dementia, sexual activity in person with dementia may provide same stress reduction, pleasure, and benefit to physical
health
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| Challenges in meeting sexual needs of couples with demented partner: physical changes; cognitive changes;
emotional changes in terms of demented person’s awareness of having dementia and of reacting to it; well partner may
have strong psychological reaction to partner’s dementia; spouse of person with dementia may be paralyzed with grief or
deny own needs; healthy spouse may feel his or her needs should be subjugated to those of partner with dementia; as dementia
progresses and personality changes, healthy partner may see demented partner as different person and no longer
feel comfortable having physical intimacy
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| Pearls: caregiver’s needs to give and to receive affection, to engage in physical intimacy, or to care for another do not disappear
with overwhelming responsibilities of giving care; counsel spouse of person with dementia that he or she has right
1) not to be abused, 2) not to participate in activity that is no longer satisfying, and 3) not to participate in activity that is
upsetting or frightening
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| Difficult questions: no one answer right for everyone; 1) is it rape if woman with dementia is compliant but does not
understand? no; if individual enjoys or initiates sexual behavior and it is mutually satisfying, sex is not rape; 2) if healthy
spouse wants to have relationships outside of marriage and children object, identify nature of their objections and counsel
them on healthy parent’s needs
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| Residential facility: limits opportunity for physical intimacy; patient who climb’s into another’s bed may not be demonstrating
inappropriate sexual behavior; he or she may simply be expressing lifelong pattern of sleeping with another;
try to understand reasons behind behavior that seems sexually inappropriate; praise and encourage acceptable behaviors;
ignore annoying behaviors; published guidelines available from several sources
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| Summary: for older people, sexual experiences common, enjoyable, and helpful; intimacy essential for optimally satisfying
sexual experience; spectrum of responses and adaptations possible when one partner develops dementia; no one right
answer for everyone; health care provider’s most important responsibility is to introduce topic, feel comfortable discussing
it, and help each couple find solution that fits their value system and spirituality
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Suggested Reading
Alagiakrishnan K et al: Sexually inappropriate behaviour in demented elderly people. Postgrad Med J 81:463, 2005;
Babor TF et al: AUDIT — The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. Geneva
Switzerland: World Health organization. Available at http://www.who.int/--substance_abuse/publications/alcohol/en; Buhr
GT, White HK: Difficult behaviors in long-term care patients with dementia. J Am Med Dir Assoc 8(3 Suppl 2):e101,
2007; Chapman BP, Lyness JM, Duberstein P: Personality and medical illness burden among older adults in primary
care. Psychosom Med 69:277, 2007; Dhikav V, Anand K, Aggarwal N: Grossly disinhibited sexual behavior
in dementia of Alzheimer’s type. Arch Sex Behav 36:133, 2007; Epstein EE, Fischer-Elber K, Al-Otaiba Z:
Women, aging, and alcohol use disorders. J Women Aging 19:31, 2007; Fleming M: Identification and treatment of alcohol
use disorders in older adults. In: Gurmack AE, Atkinson R, Osgood JN: Treating Alcohol and Drug Abuse in the Elderly.
p 85. New York, NY: Springer Publishing, 2002; Johnson C, Knight C, Alderman N: Challenges associated
with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment.
Brain Inj 20:687, 2006; Kirchner JE et al: Alcohol consumption among older adults in primary care. J Gen
Intern Med 22:92, 2007; Lang I et al: Moderate alcohol consumption in older adults is associated with better cognition
and well-being than abstinence. Age Ageing 36:256, 2007; Liberto JG, Oslin DW, Ruskin PE: Alcoholism in the
older population. In: Carstensen LL, Edelstein BA, Dornbrand L: The Practical Handbook of Gerontology. P 324. Thousand
Oaks, CA: Sage Publications, Inc.; 1996; O’Connell H: Alcohol use disorders in older people. Ir Med J 100:345,
2007; Sattar SP et al: Impact of problem alcohol use on patient behavior and caregiver burden in a geriatric assessment
clinic. J Geriatr Psychiatry Neurol 20:120, 2007; Sorock GS et al: Alcohol-drinking history and fatal injury in older
adults. Alcohol 40:193, 2006; Zuccala G et al: Italiano di Farmacoepidemiologia nell Anziano Investigators. Dose-related
impact of alcohol consumption on cognitive function in advanced age: results of a multicenter survey. Alcohol Clin
Exp Res 25:1743, 2001.
Educational Objectives
| The goal of this program is to explore alcohol use and sexuality in older people. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. Describe how the use and effects of alcohol differ in people of different ages.
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| 2. Assess alcohol use in older people and recommend appropriate treatment.
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| 3. State the myths associated with sexual activity among older individuals.
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| 4. Discuss sex comfortably with patients, especially older couples.
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| 5. Discuss the ways in which dementia in one partner can affect the sexual intimacy of couples.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, the Audio-Digest Foundation requires all faculty members to
disclose relevant financial relationships within the past 12 months that might create any personal conflict of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care education and not a
proprietary business or commercial interest. For this program, Dr. Sewell disclosed that his partner is a shareholder in Forest
Pharmaceuticals, and he is on the Speakers’ Bureaus of AstraZenica and Abbott Laboratories.
Acknowledgements
Drs. Wall and Sewell were recorded at The West Coast Geriatric Psychiatry Conference, held March 7-10, 2007, in San Diego,
California, and sponsored by the University of California, San Diego, School of Medicine. The Audio-Digest Foundation
thanks the speakers and UCSD for their cooperation in the production of this program.
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