Special Report: STI Rate Has Doubled Among Senior Citizens : Emergency Medicine News

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Special Report

Special Report

STI Rate Has Doubled Among Senior Citizens

Shaw, Gina

Emergency Medicine News 42(11):p 18-19, November 2020. | DOI: 10.1097/01.EEM.0000722388.18510.27
    FU1-4
    Figure:
    sexually transmitted infection

    Consider two hypothetical cases. A 76-year-old woman, widowed two years earlier and living independently at home, presents to the ED with dysuria, vaginal discharge, and pain in her lower abdomen. An 80-year-old man, who last year moved into a long-term care facility, presents to the ED with a fever, chills, muscle aches, and fatigue.

    With the first patient, you might initially suspect bacterial cystitis or a urinary tract infection, but your first thought for the second patient might be influenza. Those might well be the correct diagnoses, but it's also entirely possible that the woman has gonorrhea and the man has an HIV infection that has progressed to AIDS.

    “I've had a number of cases in which I've been evaluating a post-menopausal woman for a chief complaint of painful urination, and I'm looking at the urine sample thinking she probably has a urinary tract infection, and when I'm explaining that to the patient, she's asked me, ‘Do you think this could be an STD?’” said Joelle Borhart, MD, an associate professor of emergency medicine at Georgetown University Hospital and Washington Hospital Center, who spoke on sexually transmitted infections (STIs) at the American Academy of Emergency Medicine Scientific Assembly last year.

    “It hadn't even occurred to me to ask about that until the patient prompted me to consider it,” she said. “That speaks to the fact that the issue of sexually transmitted infections tends to fall off our differential radar when we are taking care of older patients.”

    It shouldn't. Data from the Centers for Disease Control and Prevention released last year show that cases of several common sexually transmitted infections (STIs)—including chlamydia, gonorrhea, and syphilis—have reached historic highs in recent years, and older Americans are seeing the steepest increases in these infections. (https://bit.ly/3kKUyyJ.)

    Rate Doubled

    That doesn't mean that individuals 55 and older have the highest rates of STIs—in fact, just the opposite. This group's average population-adjusted rate of chlamydia, gonorrhea, and primary and secondary syphilis of 24.5 per 100,000 people is actually the lowest of all age groups. But it's more than doubled in the past five years, from an average rate of 11.8 per 100,000 in 2014.

    - Cases of Gonorrhea in Adults 55 and Older
    2014 5460
    2018 14,423
    Increase 164.2%
    Source: Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance, 2018; https://bit.ly/3kKUyyJ. Photo: Lippincott Williams & Wilkins, 2013.

    The rate of HIV among older Americans is also significant. Nearly 39,000 Americans were diagnosed with HIV in 2017, and approximately 17 percent of them were 50 or older. And those who are not diagnosed with HIV until they are older are more likely than younger people to present with a late-stage HIV infection.

    A number of theories could be behind the dramatic increase in STI rates among older adults, ranging from increased use of medications for erectile dysfunction to longer life expectancies, new relationships, divorce, and death of spouses, Dr. Borhart said.

    There is often a misperception that older adults are not sexually active, while in fact, a significant percentage of seniors remain sexually active until quite late in life. “Surveys show that among men 75-87 years of age, about 40 percent report having been sexually active within the prior 12 months,” said Angela Catic, MD, an assistant professor in the Huffington Center on Aging and the director of the geriatric medicine fellowship at Baylor College of Medicine.

    “Among women the same age, that percentage is almost 20 percent,” she said. “Many times, physicians make an inappropriate assumption that someone is sexually inactive or monogamous based on age, marital status, or place of residence—such as a long-term care facility—and that's doing our patients a disservice. In senior living communities, there are lots of older adults living in relatively close proximity to each other, and sexual relationships do develop. That has been a place where we've seen a significant increase in STIs.”

    The Clinical Picture

    Dr. Catic said older adults today are different from those 20 years ago; they're living longer, are generally healthier and more active, and their chronic diseases are better controlled.

    Among adults who are sexually active, she noted, only about one in five uses condoms. “That's a major contributing factor to the rise of STIs among older adults in the last several years, especially outside of longstanding monogamous relationships, which is something we're seeing more and more of.”

    Dr. Catic said the rate of advanced illness in older adults with HIV is particularly concerning. “Among people over 50 with new HIV diagnoses, 35 percent of them already have AIDS at the time of diagnosis. Many times, when older adults are presenting to the ED or primary care with symptoms like weight loss and failure to thrive, we go down pathways related to typical age-related causes without thinking of HIV. But almost 20 percent of new HIV diagnoses are in people 50 years of age or older.”

    Her primary message to emergency physicians: If the symptoms would prompt you to take a sexual history in a younger patient, you should take one in an older patient as well. “Even in geriatrics, we're not as good as we should be about asking for this information,” Dr. Catic said. “And in primary care, only about half of all visits with older adults include a discussion of sexual health. That means we're missing important information.”

    FU2-4
    Figure
    - Cases of Chlamydia in Adults 55 and Older
    2014 7976
    2018 14,867
    Increase 86.4%
    Source: Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance, 2018; https://bit.ly/3kKUyyJ. Photo: Lippincott Williams & Wilkins, 2001.

    She also reminded clinicians that older women tend to have less estrogen compared with premenopausal women, so they may experience more vaginal dryness and irritation, which may muddy the clinical picture.

    Take a Sexual History

    You can preface the discussion with a general introduction like, “As part of taking a medical history on all my patients, I ask questions regarding sexual activity so that I have complete information and can treat you to the best of my ability. Is that OK with you?” If the patient agrees, you can then ask basic questions such as:

    • Are you sexually active?
    • How many partners do you currently have?
    • Are your partners male, female, or both?
    • Do you have a previous history of STIs?
    • How often do you use condoms?
    • Do you have any concerns or questions regarding your sexual activity?

    To make the conversation more open and comfortable, Dr. Catic advised discussing sexual health when caregivers or family members are out of the room. “That's a parallel that geriatrics shares with pediatrics,” she said. “I vividly recall a patient sharing with me about a new sexual relationship, and then saying, ‘But don't tell my daughter!’ If we want people to be honest about their sexual health, it has to be a private conversation.”

    She also urged emergency physicians to be aware that LGBTQIA+ adults may be even more reluctant than heterosexual older adults to disclose their sexual history. “They grew up in a time when things were more constrained, and very likely may have suffered discrimination at the hands of the health care system.”

    Referring Patients

    The diagnosis of sexually transmitted infections in older adults who have cognitive impairment can have its own set of complications. “We have to take into account how, through ethical and legal practices, we share that information with those who need to know,” Dr. Catic said. “There has been a great deal of debate over sexuality and intimacy among individuals with dementia, and there have even been court cases. We want to make sure that any partners involved are getting the treatment they need.”

    FU3-4
    Figure
    - Cases of Syphilis in Adults 55 and Older
    2014 1073
    2018 2366
    Increase 120.5%
    Source: Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance, 2018; https://bit.ly/3kKUyyJ. Photo: Lippincott Williams & Wilkins, 2019.

    Older men diagnosed with sexually transmitted infections are typically referred to urologists, though those with HIV are referred to infectious disease. The referral patterns for older women are sometimes less helpful, however. “Sometimes they are referred to regular gynecologists, which can be very uncomfortable as they sit in the waiting room where half the population is expecting a child and the rest are under age 30,” Dr. Catic said.

    “Urogynecologists specialize in older females and can be helpful not only with urologic issues in general but with STIs as well. That's a resource where your older female patient may feel much more at ease and get excellent care for these concerns.”

    Emergency physicians often think of the worst-case scenario first, said Dr. Borhart. “When we're considering symptoms in older men and women, we tend to think about cancer and other life-threatening issues more so than with younger patients. Because of our worst-first mindset, those are always at the top of the differential and STIs tend to fall off our radar, which can lead to delayed diagnosis. Emergency physicians should recognize that we can play an important role in the prompt diagnosis and treatment of STIs in older adults.”

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    Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.

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