Sexually Transmitted Diseases in the Aging Population
Key words: Sexually transmitted diseases (STDs) in older adults, sexual activity in older adults, HIV, chlamydia, gonorrhea.
Healthcare providers often view sexually transmitted diseases (STDs) as infections contracted by younger adults during sexual contact with infected persons. This is based on the pervasive assumption that older adults are less sexually active than their younger counterparts; however, since 2000, the number of STDs in the US population has steadily increased among persons aged 50 years and older.1,2 Chlamydia, gonorrhea, and HIV are among the most frequently reported STDs in this age group and include both newly acquired infections and residual complications.1,2 The Centers for Disease Control and Prevention (CDC) estimated that, in 2005, 15% of new HIV/AIDS infections and 24% of persons living with HIV/AIDS involved those older than 50 years; the latter statistic represents an increase from 17% in 2000.1 In 2010, the US Census Bureau estimated that 32.1% of Americans were aged 50 years and older, which equates to approximately 99,048,838 older adults.3 Despite these facts, few research studies exist regarding STDs in the aging population.4-10 One 2007 study reviewed 143 clinical trials targeting risky sexual behavior.7 This study found that 72.7% of the STD risk-reduction clinical trials excluded participants older than 50 years and 88.8% excluded those older than 65 years. Yet people do not cease engaging in sex as they age. A University of Chicago study that surveyed 3005 persons aged 57 to 85 years found that 73% of those aged 57 to 64 years, 53% of those aged 65 to 74 years, and 26% of those aged 75 to 85 years are sexually active.11 This review discusses the three most common STDs in older adults (>50 years), which include chlamydia, gonorrhea, and HIV; explains the common misconceptions held by providers and patients regarding STDs; describes STD risk factors and prevention measures; and provides suggestions for obtaining a sexual history.
Misconceptions Regarding STDs in Older Adults
Healthy People 2020 continues to recognize HIV and STDs as problems in the United States and continues to make efforts to reduce this problem.12 Prevention strategies for older adults in the primary care setting often are not aimed at HIV or STDs, and sexual behaviors tend to be talked about least. This may be partly because practitioners think sexual activity is infrequent in older patients and partly because older adults may have been socialized to avoid discussing it. Even patients who are asymptomatic and no longer sexually active, however, may have contracted an STD years earlier but were never tested and remain unaware they have such a disease. Providers may not recognize signs and symptoms of STDs in older adults or may attribute symptoms to a different cause, which can delay diagnosis and treatment. This delay not only increases the potential for complications, but also increases the risk of transmission to sexual partners,5 as demonstrated by the case scenario that follows.
A 70-year-old white man visited his primary care provider (PCP) for symptoms of weight loss and fatigue. He reported a weight loss of 20 lb and increased fatigue over the past 6 months. After undergoing neurologic testing, psychiatric testing, and routine laboratory testing to rule out cancer and thyroid disease, he received a diagnosis of Alzheimer’s disease. When the patient needed a postoperative blood transfusion several years later, his activated Power of Attorney consented to an HIV test, and the patient was found to have AIDS-related dementia, rather than Alzheimer’s disease. The PCP, however, had never taken the patient’s sexual history, assuming he was not at risk for an STD because of his age.
As this case scenario shows, such a misdiagnosis can put a patient at risk for early death from lack of treatment and put both healthcare professionals and family members at risk for contracting the disease. To avoid situations like this, providers need to be aware of the most commonly observed STDs in older adults and understand how these STDs manifest in this population so that they can make an accurate and timely diagnosis. What follows is a review of some of the most common STDs in older adults.
Most Common STDs in Older Adults
Chlamydia and gonorrhea are among the most commonly reported STDs in the United States, including among older adults. Both STDs are bacterial infections that can be treated easily with antibiotics. However, many people do not know they have these diseases because they are asymptomatic or do not have their symptoms evaluated. Yet when STDs remain untreated, they can cause many harmful complications, including cancer and facilitation of HIV transmission in all patients, as well as fetal, perinatal, and reproductive health problems in younger
Chlamydia is caused by the bacterium Chlamydia trachomatis. Women are often asymptomatic, but symptoms may include abnormal vaginal discharge, dysuria, abnormal vaginal bleeding, and pelvic pain.13 Men may report mucopurulent or purulent discharge from the urethra and burning upon urination, but many men may be asymptomatic.13 Chlamydia is a common cause of cervicitis in women and urethritis in men.13 Both sexes may experience chlamydial conjunctivitis, which can cause red and sticky discharge from one or both eyes and swollen eyelids. In some cases, the cornea may be involved. Therefore, an eye examination is a crucial part of the examination and can aid in making the diagnosis, but laboratory studies are needed to make a definitive diagnosis.14 This may include an antigen test, a urine test, or a swab culture test. When a swab culture test is used, the swab is inserted into the cervix in women and the end of the penis in men to obtain a bodily fluid sample.14
Although consequences of untreated chlamydia include sterility in persons in their reproductive years, this infection can also cause complications such as Reiter’s syndrome (a type of arthritis caused by the body’s reaction to bacterial infection), which can affect persons of any age. In addition, an association between chlamydia and cervical cancer risk has been found, and it has been suspected that chlamydia may prolong human papillomavirus (HPV).15 However, HPV appears to be one of the least common STDs in older patients. One study showed an HPV prevalence of only 6% among women aged 57 to 85 years.16 In contrast, since 1994, chlamydia has made up the largest proportion of all STDs reported to the CDC.17
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, which can grow in the cervix, uterus, fallopian tubes, urethra, mouth, throat, eyes, and anus. Symptoms can include urethritis in men and slight discharge and dysuria in women. However, many infections among women do not produce symptoms until complications have occurred, such as pelvic inflammatory disease.13 Like chlamydia, gonorrhea can also cause eye problems for both sexes, including eye pain, sensitivity to light, and pus-like discharge from the affected eye(s). Laboratory assessments are needed to make a definitive diagnosis. These tests may include culturing the bacteria, staining tests to detect the presence of the bacteria, or urine tests to detect the presence of gonorrheal DNA.18
The CDC estimates that more than 700,000 persons in the United States each year become infected with gonorrhea.19 However, only about half of these cases are reported to the CDC because not all states are required to report these statistics.
HIV is an infection that kills cells of the immune system, particularly the CD4+ T-cells (T-lymphocytes).13 Symptoms may start within 2 to 4 weeks after exposure and can include fever, chills, rash, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, and ulcers in the mouth.20 However, many individuals only start to feel ill when their HIV infection progresses to AIDS.20
The number of older adults living with HIV/AIDS has increased because patients with HIV are living longer due to better antiretroviral therapy and because there are more newly diagnosed infections in persons older than 50 years.1 Approximately 11% of new HIV infections occur in adults aged 50 years and older,21 and these patients may have the same risk factors for HIV infection and other STDs as younger adults. It has been reported that individuals with STDs are at least two to five times more likely to acquire HIV if exposed to this virus.22 This is because STDs cause inflammation, which increases the concentration of cells in genital secretions that can serve as a nidus for HIV infection.
Provider’s Role In Diagnosing STDs in Older Adults
Many healthcare professionals have misconceptions that older or elderly persons are not sexually active or assume they are in a heterosexual monogamous relationship, when they may truly be at risk for STDs.4 Sexuality and emotional health are part of a complete medical history; however, sexual histories in older patients are often not taken or are incomplete, partly because the provider feels anxious or uncomfortable discussing sexual issues compared with discussing less sensitive issues, such as gastrointestinal or cardiovascular problems.23
To obtain an accurate sexual history from patients, PCPs must first identify their personal comfort level with discussing the topic. One way to become more comfortable includes having an awareness of one’s personal beliefs, behaviors, thoughts, and feelings regarding sexuality. This may be accomplished by attending professional educational sessions or by talking with peers regarding feelings about such discussions and approaches to obtaining a sexual history. The Table also provides some tips on how to discuss sexual matters with patients.
A complete sexual history should include information about sexual partners, physical signs or symptoms, problems, and overall satisfaction.4 Sexually active patients should be asked if protection against STDs is being used. One qualitative study interviewing 519 PCPs found that 87% asked about sexual risks only when patients requested contraception.24 This approach excludes the older population completely. Healthcare professionals must also be aware that sexual abuse of older adults puts them at risk for STDs. Elder abuse is an underrecognized problem, and warning signs of sexual abuse in elders can include bruises around the breasts or genital area and unexplained STDs.25
Healthcare professionals may not be the only ones who have misconceptions about sexuality. Older adults may not believe they are at risk for STDs; however, it is estimated that the average person older than 50 years still engages in sexual activity two to four times per month.10 A study done from 1990 to 1991 using a national survey found that less than 4% of sexually active older adults with at least one risk factor for HIV infection had used condoms consistently in the preceding 6 months.10 It is important for older adults to understand that sexual activity includes anything that exposes them to bodily secretions. This includes vaginal or anal intercourse, performing or receiving oral sex, and masturbation.
The aging process also puts older adults at greater risk for STDs. The immune system declines as people age, making them more susceptible to infectious diseases. In older women, thinning of the vaginal walls after menopause can result in tears during sexual activity, facilitating disease transmission.4,10,26 In men, the aging process can result in sexual dysfunction. This is even more pronounced in patients with a chronic illness or those taking medications with sexual side effects. In men older than 60 years, the ability to ejaculate diminishes.27 The introduction of agents for the treatment of erectile dysfunction over the past 15 years may have made it easier for male patients to discuss sexual problem with their PCPs, leading to renewed sexual activity. The introduction of agents such as sildenafil into the primary care setting provides an opportunity for PCPs to ask their patients questions about their sexual history and address sexual issues, including STDs.
(Continued on next page)