a comprehensive evaluation, including a detailed history, which may require collateral information from family members and caregivers. Identification of any past trauma, especially sexual trauma, is important. Potential triggers, such as new medications, loss of a spouse, and timing (such as night‐time, after an activity, or around personal care), should be identified. Other non‐sexual causes (such as genital itching leading to groping, or overheating causing disrobing) should be excluded. Based on the findings of this detailed assessment, non‐pharmacologic strategies should be initiated to reduce or avoid triggers. Some behavioural modification strategies include physically separating the inappropriate older adult from potential victims, providing tactile stimulation that distracts them from undesired behaviours (e.g. folding towels or playing with a stuffed animal), avoiding stimulating media on television and radio, and providing clothing that does not allow for easy exposure (e.g. pants without a front zipper).49
If the above measures are not successful, pharmacologic therapies may be trialled based on specific symptoms. For example, if the sexually inappropriate behaviours coincide with psychotic features, a trial of antipsychotic may be reasonable. If there are obsessive symptoms, an SSRI could be considered. With any pharmacologic therapy, regular assessment for efficacy and side effects, and trials of de‐prescribing, are necessary. Unfortunately, there is little research on non‐pharmacologic interventions for sexually inappropriate behaviour. Case reports have described pharmacologic strategies for reducing sexually inappropriate behaviours, but this is controversial, and no strong evidence exists for one medication over another. Approaches have included antipsychotics, antidepressants, rivastigmine, anticonvulsants (carbamazepine, gabapentin), beta blockers, and anti‐androgens (including hormonal and non‐hormonal approaches).49,50
Sexually transmitted infections
Clinicians should be mindful that older adults remain at risk for sexually transmitted infections (STIs) and that sexual risk‐taking behaviour is not only a problem of younger people. Postmenopausal women are considered to be at a higher risk of contracting STIs than younger women due to increased friability of the vaginal mucosa, leading to abrasions and tears during intercourse. Older adults are less likely than younger adults to have adequate knowledge about STIs and human immunodeficiency virus (HIV).51 It is essential that older people are informed and equipped to enjoy sexual activity safely. Older people are increasingly at risk of sexually transmitted disease, and, compared to younger adults, they tend to delay seeking help after the onset of symptoms.52 The US Centers for Disease Control reported increasing rates of chlamydia, gonorrhoea, and syphilis among Americans over the age of 65 from 2013 to 2017.52 A study in the UK showed increased rates of syphilis, gonorrhoea, chlamydia, anogenital warts, and anogenital herpes between 1996 and 2003 among older adults.53 In the US, people over the age of 50 constituted 17% of new HIV diagnoses in 2016, and 35% of people 50 and older already had AIDS when they received their HIV diagnosis.54
There are many misconceptions about STI and HIV prevention among older adults, including perceptions that personal hygiene, physical characteristics of partners, personal behaviour, and monogamy are protective.55 It is important for health professionals to recognize that many older people have not benefited from health education programmes and may be unaware of the protection provided by condoms.53 One large survey of Americans aged 14–97 revealed that adults over the age of 70 had the lowest rates of condom usage out of all age groups surveyed, at 5.4% of men and 1.9% of women.56 Healthcare providers should use age‐appropriate educational materials and increase education for older adults about sexual health and sexually risky behaviours.51 As stated above, patients should also be counselled that oil‐based lubricants can affect the efficacy of condoms in preventing STIs.
Additionally, many older adults who lived through the worldwide HIV/AIDS epidemic in the 1980s and 1990s are now ageing. Due to the efficacy of highly active antiretroviral therapy, patients with HIV who receive appropriate treatment can generally expect a normal or near‐normal life expectancy. It is essential that older adults recognize the increased prevalence of HIV among their demographic and familiarize themselves with issues unique to ageing and HIV. Specifically, older adults with HIV may have unpredictable pharmacology due to a decline in liver and kidney function. As older adults are often on multiple medications for chronic conditions, they are at higher risk of drug‐drug interactions due to unpredictable drug clearance and polypharmacy. Appropriate dosing of HAART medications in older adults is an area of active research. Older adults may need more frequent laboratory monitoring of liver and kidney function than younger patients. In addition, older adults with cognitive impairment or functional mobility are at increased risk of nonadherence, leading to treatment failure. Simplified regimens, combination pills, reducing non‐essential medications, and behavioural modifications such as phone alarms and pillboxes can all help to improve adherence. Even with appropriate treatment, HIV increases the risk of dementia, bone loss, and certain cancers due to effects on the immune system. Finally, older adults may face stigmatization from their diagnosis and are at increased risk of social isolation.57
Special considerations for LGBTQ older adults
Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people have become more visible in recent years, and recent estimates suggest that there are over 3 million LGBTQ adults over the age of 65 in the United States. Older adults in same‐sex relationships have generally reported being highly sexually satisfied, with a high correlation between relationship satisfaction and sexual satisfaction.58 For some people who may have grown up with intolerant and discriminatory families or had gender reassignment surgery, being an older adult can feel sexually liberating.7 In many ways, the sexual needs of LGBTQ older adults are similar to those of heterosexual people; however, their experiences of bias, prejudice, and insensitivity may impact how they interact with the healthcare community.
This is a population historically underserved and underrepresented in research for many reasons. Compared with heterosexual people, LGBTQ people face increased chronic societal stress due to potential bias, stigmatization, and discrimination, and studies have shown that they do not always disclose their sexual orientation to healthcare providers. Factors that may increase someone’s willingness to disclose include having a gender and race congruent provider (e.g. a white gay man may feel more comfortable disclosing to a provider who is also white and male), having a provider who is also LGBTQ, and having a perception that the provider will respond positively.59 Healthcare providers should remember that LGBTQ older adults may have experienced significant discrimination over the course of their lives, which may cause them to feel uncomfortable disclosing their sexual orientation.45 This may improve over time, as a younger generation of LGBTQ people age in a society that is more accepting of sexual diversity.
Healthcare providers should try to avoid heteronormative assumptions and include all patient‐designated partners and loved ones in important medical decision‐making. LGBTQ older adults may have significant anxiety about potential late‐life events, end‐of‐life needs, and legal issues. For LGBTQ people, there may be differences between one’s ‘families of origin’ and their ‘families of choice’.45 Especially in couples who are not legally married, having a designated surrogate decision‐maker and clear advance directives may be vitally important to ensure the patient’s wishes are honoured.
Sexuality in the nursing home
Sexuality does not necessarily cease on entry into a nursing home. However, there are multiple barriers to sexuality within the nursing home, including lack of privacy, lack of a partner, and staff, family, and resident attitudes and knowledge concerning sexuality.7 There has been a movement toward permissive attitudes among nursing home staff regarding sexual activity of residents through staff education and incorporation of sexual policies into residents’ rights documentation at many facilities.49 Despite this, for some partners of people in nursing homes, a perceived lack of privacy may make sexual activity undesirable.7
For residents with dementia, careful and repeated evaluation