Abstract
Objective:
The aim of this study was to identify the unique impact of mild cognitive impairment (MCI) on sexual activity among older adults.
Methods:
Data for the study were drawn from a national survey entitled the “Determinants of Wellness among Older Malaysians: A Health Promotion Perspective” conducted in 2010.
Results:
According to the Mini-Mental State Examination education-adjusted cutoff points, 15.6% of the 1046 respondents were identified as having MCI. Older adults with MCI had a significantly lower level of sexual activity than the healthy cognitive group (chi-square = 50.20, P < .001, 32.5% vs 62.3%). The results of 3-step hierarchical logistic regression model revealed that MCI is significantly associated with decreased sexual activity in community-dwelling older adults, over and beyond demographic factors, and age-related medical conditions affecting sexual activity (odds ratio 0.33, P < .001, 95% confidence interval 0.23-0.49).
Conclusion:
Findings from the present study support the significant role of cognitive functioning to perform sexual activity in later life.
Keywords: aged, Malaysia, mild cognitive impairment, sexual activity, sexuality
Introduction
The significant increase in the elderly population due to the extension of the life expectancy has led to an increase in the prevalence of cognitive impairment. As the prevalence of cognitive impairment increases, maintaining quality of life at the end of life becomes a growing concern. 1–3 Mild cognitive impairment (MCI) is widely considered as a transition phase between healthy cognitive aging and Alzheimer’s disease. 4 According to population-based studies around the world, the prevalence of MCI ranged from 3% to 20%. 5 It has been shown that MCI is associated with increased difficulties in the performance of a wide range of everyday tasks, 6 poorer instrumental activities of daily living functioning, 7 low-quality of life, 8,9 depression, 10 low-survival rate, 11 and double risk of death, 12 Although MCI has received considerable attention in aging research over the past few years, 1 arena of study that has largely been neglected is the impact of MCI on sexuality as a part of human nature throughout life. Therefore, the current study aimed to identify the unique contribution of MCI to the prediction of sexual activity among older adults.
Methodology
Data for this study, consisted of 1046 married older adults aged 60 years and older, were obtained from the national survey titled “Determinants of Wellness among Older Malaysian: A Health Promotion Perspective.” This community-based, cross-sectional survey was carried out in 2010. A multistage random sampling technique with a response rate of 77% was employed to obtain a representative sample of older adults aged 60 years and older. Data collection was conducted by trained enumerators in face-to-face interviews.
Ethics and Approvals
The study was approved by the Ministry of Health, Malaysia, and it was in compliance with the Helsinki Declaration, World Medical Association.
Measures
Mild Cognitive Impairment
The Mini-Mental State Examination (MMSE) was used to assess cognitive disorders, which includes 30-items component of orientation, attention, calculation, language, and recall. The best cutoff point detecting cognitive disorders in illiterate patients was 18 of 19; and among those educated, the best cutoff point was 24 of 25, 13 Although MMSE offers modest accuracy for ruling out a diagnosis of MCI, 14 it has widely been used in both clinical practice and research and suggested as a useful instrument in screening for cognitive impairment in the guidelines for the Report of the Quality Standards Subcommittee of the American Academy of Neurology. 15
Sexual Activity
Although sexual activity includes a broad range of human behaviors from kissing to sexual intercourse, 16 in line with some previous studies focusing on older adults’ sexual activity, 17–19 in this study sexual activity was defined as sexual intercourse. To measure the sexual activity, respondents were asked on whether they have had any sexual intercourse within 12 months before the survey.
Medical conditions including hypertension, diabetes, gastritis, joint pain (arthritis), and visual problems were assessed by the self-report method.
Statistical Methods
Data analyses, including descriptive and inferential statistics, were performed using SPSS software (Version 21; SPSS Inc, Chicago, Illinois). A 3-step hierarchical logistic regression model was used to determine the unique contribution of MCI to the prediction of sexual activity. In the first step, the main independent variable (MCI) was entered. In the second step, demographic variables (age, gender, education, and household income) were entered into the analysis. Finally, to determine whether MCI contributed uniquely to the prediction of sexual activity even when controlling for common chronic medical conditions related to sexual activity, hypertension, diabetes, gastritis, arthritis, and visual problems were added (Model 3). The Hosmer and Lemeshow test was used to assess goodness of fit.
Results
Among the 1046 respondents, mean age was 67.31 years (standard deviation [SD] = 6.06 years, ranging from 60 to 92 years), and 61.5% of respondents were men. The mean cognitive function score was 26.20 (SD = 4.93). The total prevalence rate of MCI was 15.6%. Older adults with MCI had significantly lower level of sexual activity compared to the healthy cognitive group (chi-square (χ2) = 50.20, P < .001, 32.5% vs 62.3%). Table 1 presents the basic demographic characteristics, MCI, and health status of the study population according to their sexual activity.
Table 1.
Prevalence of Sexual Activity According to MCI, Demographic, and Health Factors.
| Variable | Category | Total | Sexual Activity | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| MCI | Healthy | 883 | 84.4 | 550 | 62.3 |
| MCI | 163 | 15.6 | 53 | 32.5 | |
| Gender | Male | 643 | 61.5 | 399 | 62.1 |
| Female | 403 | 38.5 | 204 | 50.6 | |
| Age | 60-69 | 733 | 70.1 | 482 | 65.8 |
| 70-79 | 267 | 25.5 | 118 | 44.2 | |
| 80+ | 46 | 4.4 | 3 | 6.5 | |
| Education | No formal | 280 | 26.8 | 113 | 40.4 |
| Primary | 546 | 52.2 | 325 | 59.5 | |
| Secondary and tertiary | 220 | 21 | 165 | 75 | |
| Income | <300 | 230 | 22 | 105 | 45.7 |
| 300-800 | 461 | 44.1 | 263 | 57 | |
| >800 | 355 | 33.9 | 235 | 66.2 | |
| Hypertension | 450 | 43 | 238 | 52.9 | |
| Diabetes | 205 | 19.6 | 103 | 50.2 | |
| Gastritis | 75 | 7.2 | 28 | 37.3 | |
| Arthritis | 385 | 36.8 | 197 | 51.2 | |
| Visual problem | 282 | 27 | 143 | 50.7 | |
Abbreviation: MCI, mild cognitive impairment.
The Results of 3-Step Hierarchical Logistic Regression
Table 2 reveals the results of a 3-step hierarchical logistic regression analysis in which sexual activity was regressed on MCI after controlling for demographic profile (age, gender, education, and household income) and age-related medical conditions affecting sexual activity. The results of the first step of the hierarchical logistic regression in which sexual activity was regressed on the MCI revealed a significant model χ2(1) = 49.90, P < .001, and Nagelkerke R2 =.063. Model 2, incorporating the demographic variables age, gender, education, household income, was highly significant, χ 2 (8) = 181.77, P < .001, and Nagelkerke R2 = .215. As expected, a higher level of education was significantly associated with increased sexual activity, while gender (being female) and older age were significantly and negatively correlated with sexual activity. Model 3, in which some age-related medical conditions were added as a predictor, was highly significant, χ 2 (13) = 206.23, P < .001, and Nagelkerke R2 = .241. As expected, the model revealed that older adults with MCI were 67% less likely to have sexual activity (odds ratio 0.33, P < .001, 95% confidence interval 0.23-0.49). Overall, elderly individuals with MCI were significantly less likely to engage in sexual activity than those who were cognitively healthy.
Table 2.
Results of 3-Step Hierarchical Multiple Logistic Regression.
| Items | First Model | Second Model | Third Model | |||
|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| MCI | 0.29a | 0.2-0.41 | 0.35a | 0.24-0.51 | 0.33a | 0.23-0.49 |
| Gender (being female) | 0.58a | 0.44-0.77 | 0.60b | 0.45-0.81 | ||
| Age (ref: 60-69) | ||||||
| 70-79 | 0.43a | 0.32-0.59 | 0.44a | 0.32-0.6 | ||
| 80+ | 0.04a | 0.01-0.13 | 0.04a | 0.01-0.13 | ||
| Education (ref: no formal) | ||||||
| Primary | 1.54b | 1.11-2.14 | 1.58b | 1.13-2.21 | ||
| Secondary and tertiary | 2.65 | 1.7-4.12 | 2.55a | 1.62-4 | ||
| Income (ref: ≤300) | ||||||
| 300-800 | 1.07 | 0.75-1.53 | 1.1 | 0.77-1.58 | ||
| >800 | 1.13 | 0.76-1.67 | 1.18 | 0.79-1.75 | ||
| Hypertension | 0.74c | 0.55-0.99 | ||||
| Diabetes | 0.65c | 0.46-0.92 | ||||
| Gastritis | 0.54c | 0.32-0.93 | ||||
| Arthritis | 0.87 | 0.64-1.17 | ||||
| Visual problem | 0.92 | 0.67-1.27 | ||||
Abbreviations: CI, confidence interval; MCI, mild cognitive impairment; OR, odds ratio.
a P ≤ .001.
b P ≤ .01.
c P ≤ .05.
Discussion
The prevalence of MCI in this study ranged from 3% to 20% and was consistent with previous population-based studies. 5 The findings from our study showed that only around one-third of the older adults with MCI have sexual activity compared to 62.3% of the healthy cognitive group, indicating that MCI negatively affects sexual activity in old age. In a study based on a sample of older adults with mild to moderate dementia, Ballard and his colleagues 20 found that only 22.5% of the couples involved in a continuing sexual relationship. The main objective of this current study was to examine the impact of MCI on sexual activity after controlling for possible sociodemographic and health risk factors. The findings from 3-step hierarchical logistic regression analyses revealed that MCI is significantly associated with decreased sexual activity in community-dwelling older adults after controlling for known sociodemographic correlates such as age, gender, education, household income, 21 and several medical conditions affecting sexual activity such as hypertension, diabetes, arthritis, visual problems, 22 and gastritis. 23
Major factors that may contribute to decreased sexual activity among older adults with MCI can be classified into 4 categories. First group of factors is organic changes in aging such as neuropathy, vasculopathy, reduced sex hormones, and erectile dysfunction. Second group of factors is related to relationship changes including bereavement and role transition from caregiver to care recipient. The third group of factors is associated with health conditions such as diabetes and depression. Finally, the use of prescribed medicine can impair sexual drive and performance, for example anticholinergics and antipsychotics can cause impotence and impaired ejaculation. 24
The findings from the present study did support the significant role of cognitive functioning to perform sexual activity in later life, wherein MCI is associated with decreased sexual activity. With regard to the substantial role of sexuality on quality of life in old age, 25 early diagnosis and therapeutic interventions for sexual issues among older adults with MCI are suggested. In addition, since sexual problems of older adults with cognitive impairment may affect their partner’s sexuality, 26 therapeutic interventions may need to be developed for spouses of elderly people having MCI to assist them to modify activities, behaviors, and expectations about their sexual relationships. Since, to the best of our knowledge, this study is one of the first studies to report population-level data on relationship between MCI and sexual activity among older adults, future studies will need to investigate possible biopsychosocial pathways linking MCI to sexual problems in later life.
The findings should be interpreted in the context of study limitations. The study used an existing data set designed to explore older adults’ wellness; therefore, the item used to measure sexual activity did not identify type of all sexual behaviors, and the definition of sexual activity was limited to intercourse. Since partner issues may influence older adults’ sexual activity, 26 the second possible limitation that should be addressed is that respondents’ spouses were not interviewed in this study; therefore, future study should include both spouses. Another limitation is the cross-sectional nature of the study, which might limit its ability to make definitive conclusion about the impacts of MCI on sexual activity in later life. Therefore, a longitudinal research approach would be useful to capture the causal relationship between MCI and sexuality.
Despite the acknowledged limitations, the findings of this study may increase health professionals’ awareness and stimulate future research initiatives in the development and evaluation of the early preventive and therapeutic interventions for maintaining and improving sexuality among older adults with MCI.
Footnotes
Authors’ Note: YAM contributed to literature review, data analysis, and writing of the manuscript; RI shared in writing the first and final version of the manuscript; and TAH designed and managed the project.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was supported by the National Medical Research Register (Project Code: NMRR-09-443-4148).
References
- 1. Momtaz YA, Hamid TA, Yusoff S, Ibrahim R. Do depression and educational attainment mediate the association between ethnicity and dementia. Gerontology. 2013;59(3):206–212. [DOI] [PubMed] [Google Scholar]
- 2. Momtaz YA, Hamid TA, Ibrahim R. Unmet needs among disabled elderly Malaysians. Soc Sci Med. 2012;75(5):859–863. [DOI] [PubMed] [Google Scholar]
- 3. Momtaz YA, Hamid TA, Yusoff S, et al. Loneliness as a risk factor for hypertension in later life. J Aging Health. 2012;24(4):696–710. [DOI] [PubMed] [Google Scholar]
- 4. Roberto KA, McCann BR, Blieszner R. Trajectories of care: spouses coping with changes related to mild cognitive impairment. Dementia. 2013 2011;12(1):45–62. [DOI] [PubMed] [Google Scholar]
- 5. Busse A, Bischkopf J, Riedel-Heller S, Angermeyer MC. Mild cognitive impairment: Prevalence and incidence according to different diagnostic criteria: results of the Leipzig longitudinal study of the aged (LEILA75+). Br J Psychiatry. 2003;182(5):449–454. [PubMed] [Google Scholar]
- 6. Artero S, Touchon J, Ritchie K. Disability and mild cognitive impairment: a longitudinal population-based study. Int J Geriatr Psychiatry. 2001;16(11):1092–1097. [DOI] [PubMed] [Google Scholar]
- 7. Burton CL, Strauss E, Bunce D, Hunter MA, Hultsch DF. Functional abilities in older adults with mild cognitive impairment. Gerontology. 2009;55(5):570–581. [DOI] [PubMed] [Google Scholar]
- 8. Muangpaisan W, Assantachai P, Intalapaporn S, Pisansalakij D. Quality of life of the community-based patients with mild cognitive impairment. Geriatr Gerontol Int. 2008;8(2):80–85. [DOI] [PubMed] [Google Scholar]
- 9. Teng E, Tassniyom K, Lu PH. Reduced quality-of-life ratings in mild cognitive impairment: analyses of subject and informant responses. Am J Geriatr Psychiatry. 2012;20(12):1016–1025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Vinkers DJ, Gussekloo J, Stek ML, Westendorp RG, Mast RC. Temporal relation between depression and cognitive impairment in old age: prospective population based study. BMJ. 2004;329(7471):881. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Gussekloo J, Westendorp RG, Remarque EJ, Lagaay AM, Heeren TJ, Knook DL. Impact of mild cognitive impairment on survival in very elderly people: cohort study. BMJ. 1997;315(7115):1053–1054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Ritchie K. Mild cognitive impairment: an epidemiological perspective. Dialogues Clin Neurosci. 2004;6(4):401–408. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. LourencoI RA, Vera RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saude Publica. 2006;40(4):712–719. [DOI] [PubMed] [Google Scholar]
- 14. Mitchell AJ. A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment. J Psychiatr Res. 2009;43(4):411–431. [DOI] [PubMed] [Google Scholar]
- 15. Moretti F, Atti AR, Cesano S, et al. The use of MMSE to identify mild cognitive impairment (MCI). A population-based study. Eur Psychiatry. 2009;24(suppl 1):S853. [Google Scholar]
- 16. O'Sullivan LF, Allgeier ER. Feigning sexual desire: consenting to unwanted sexual activity in heterosexual dating relationships. J Sex Res. 1998;35(3):234–243. [Google Scholar]
- 17. Moreira ED, Jr, Glasser DB, Gingell C. Sexual activity, sexual dysfunction and associated help-seeking behaviours in middle-aged and older adults in Spain: a population survey. World J Urol. 2005;23(6):422–429. [DOI] [PubMed] [Google Scholar]
- 18. Beckman N, Waern M, Gustafson D, Skoog I. Secular trends in self reported sexual activity and satisfaction in Swedish 70 year olds: cross sectional survey of four populations, 1971-2001. BMJ. 2008;337(7662):151–154. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Kontula OJ. Sexual activity and sexual desire at the age over 45. J Sex Res. 2008;45(2):95–95. [Google Scholar]
- 20. Ballard CG, Solis M, Gahir M, et al. Sexual relationships in married dementia sufferers. Int J Geriatr Psychiatry. 1997;12(4):447–451. [PubMed] [Google Scholar]
- 21. Addis IB, Van Den Eeden SK, Wassel-Fyr CL, Vittinghoff E, Brown JS, Thom DH. Sexual activity and function in middle-aged and older women. Obstet Gynecol. 2006;107(4):755–764. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. McNicoll L. Issues of sexuality in the elderly. Med Health R I. 2008;91(10):321–322. [PubMed] [Google Scholar]
- 23. eHealthMe. Gastritis and Sexual Dysfunction: Could Gastritis Cause Sexual Dysfunction; 2013. http://www.ehealthme.com/cs/gastritis/sexual+dysfunction+-+male. Accessed December 4, 2013
- 24. Series H, Degano P. Hypersexuality in dementia. Adv Psychiatr Treat. 2005;11(6):424–431. [Google Scholar]
- 25. Robinson JG, Molzahn AE. Sexuality and quality of life. J Gerontological Nurs. 2007;33(3):19–27. [DOI] [PubMed] [Google Scholar]
- 26. Davies HD, Newkirk LA, Pitts CB, et al. The impact of dementia and mild memory impairment (MMI) on intimacy and sexuality in spousal relationships. Int Psychogeriatr. 2010;22(4):618–628. [DOI] [PubMed] [Google Scholar]