Correlates of chronic disease and patient–provider discussions among middle-aged and older adult males: Implications for successful aging and sexuality

Abstract

Objective: Effective erectile dysfunction (ED) treatments and cardiovascular disease (CVD) and diabetes risk assessments are available, but require patient–provider communication. The present study explored this issue using 2010 National Social Life, Health and Aging Project data for males age 57 years and older (n = 1011).Methods: Multinomial logistic regression was performed to compare factors associated with being without CVD/diabetes (39.9%), being diagnosed with CVD only (43.1%), and having comorbid CVD/diabetes (CVD 17.0%). Logistic regression compared factors associated with having ever discussed sexual issues with physicians.Results: CVD-only participants were more likely to be ≥75 years (p = 0.004) and smoke (p = 0.019); CVD&D participants were more likely to report activity limitations (p < 0.001) and less likely to have sex within the previous year (p = 0.014). Compared to CVD-only, men with CVD&D were more likely to be minorities, obese, have daily activity limitations, and report erectile difficulties (all p < 0.05). Males discussing sexual issues with physicians were more likely to report higher education [OR = 1.68, p = 0.001], have sex in previous year [OR = 1.73, p = 0.006], and have erectile difficulties [OR = 2.26, p < 0.001].Discussion: Increased patient and provider awareness and communication are needed to lifestyle behaviors, promote self-care practices, and improve health care utilization among male patients affected by chronic disease and ED.

Keywords::

• Cardiovascular disease
• diabetes
• sexual dysfunction
• erectile dysfunction
• physician interaction

Introduction

Twin demographic trends are changing the American sociocultural landscape in the 21st century—Americans are living longer and populations of racial/ethnic minorities are increasing in size [1,2]. The number of Americans age 65 years and older will likely double over the next three decades. By the year 2050, the number of older African Americans and Latinos will increase 3-fold and 11-fold, respectively [1]. Medical and scientific advances are increasing Americans’ potential for successful aging, which may be defined as “a lifelong process optimizing opportunities for improving and preserving health and physical, social, and mental wellness; independence; quality of life; and successful life-course transitions.” [3] Traditionally, aging research has focused more on issues of morbidity and mortality relative to the emerging body of literature exploring its positive aspects [3,4]. However, studying morbidity and mortality often yields evidence of clinically modifiable factors, which may fuel primary and secondary prevention efforts. Cardiovascular disease (CVD) and diabetes research provide two exemplars of this trend.

CVD, including stroke, hypertension, and coronary heart disease, is the leading cause of mortality in the U.S. [5]. With the “graying of America,” an estimated 40.5% of older adults will have CVD by 2030, resulting in direct medical costs of US$818.1 billion per year [5]. A number of racial/ethnic groups, particularly African Americans, are disproportionately affected by CVD. Common physical CVD-related complaints include angina, shortness of breath, arrhythmia, nausea, and fatigue, which may adversely affect patients’ ability to participate in activities of daily living and health-promoting activities such as exercise [6]. Mental ailments (e.g. depression and anxiety) may have profoundly negative effects on health-related quality of life [7].

Diabetes, a comorbid risk factor for development of CVD, has an analogous effect on public health. Diabetes is the seventh leading cause of mortality in the United States and currently affects approximately 26.9% of US adults age 65 years and older [8]. Common diabetes-related complaints include reduced capacity for wound healing, frequent urination, irritability, weight loss, and blurred vision. Some effects such as fatigue, depression, and erectile dysfunction (ED) overlap with CVD, placing many patients with diabetes at an increased risk for severely impaired health-related quality of life [9,10].

While the prevalence and severity of erectile dysfunction increases with age [11], sexual dysfunction is not necessarily an inevitable consequence of aging. ED is now acknowledged as both a “predictor and marker” of CVD and appears more than 10 years earlier in patients with diabetes than the general population [9,12,13]. Men with CVD, diabetes, or both conditions are more likely to experience sexual problems than their counterparts without these conditions [11,13,14]. Some studies estimate that as many as 80% of older adult males with diabetes experience difficulties achieving or maintaining erections [15].

Given the roles of CVD and diabetes (CVD&D) in increasing morbidity and mortality and decrements in sexual activity for large numbers of older males, this manuscript assesses predictors of sexual communication between a community-dwelling sample of older adult males affected by CVD only and comorbid CVD&D and their health care providers. The specific purposes of this study were to (i) describe sociodemographic variables, health indicators and behaviors, and self-reported sexual dysfunctions associated with chronic disease status and having discussed sex with a physician since turning age 50; (ii) identify these factors’ association with participants’ diagnosis with CVD only and comorbid CVD and (iii) identify sociodemographics, health indicators, health behaviors, self-reported sexual dysfunctions, and chronic disease status associated with discussing sex with a physician since turning age 50. Implications for clinical practice and research are discussed.

Methods

Study participants and procedures

The National Social Life, Health, and Aging Project (NSHAP) is a nationally representative probability survey of over 3000 community-dwelling men and women between the ages of 57 and 85 years [16]. Its aim was to collect a variety of data on intimate details of older adults’ lives including their physical health status, mental health status, medication usage, social networks, and sexual relationships [16]. Data were collected through a combination of in-home interviews, “leave-behind” surveys, and biomeasure collections as part of a randomized multiarm study design, which oversampled African Americans and Hispanics [17,18]. A follow-up study occurred 5 years after initial data collection. The current study is a cross-sectional examination of 1101 male cases from the 2010 administration of this longitudinal project.

Measures

Dependent variable

The dependent variables were the participants’ disease diagnoses and whether or not they had ever discussed sexual matters with a physician. For the purpose of this study, self-reported disease diagnosis categories included having neither CVD nor diabetes; CVD only; or both CVD and diabetes (CVD&D). Self-reported patient–physician communication about sexual health was assessed using one item that asked participants, “Since you turned 50, have you ever discussed sex with a doctor?” Responses were recorded as “yes” or “no.”

Health indicators

A variety of measures were used to assess indicators of participants’ health status. Body mass index (BMI) was calculated from participants’ self-reported height (in feet and inches) and weight (in pounds), which were converted to meters and kilograms, respectively. BMI levels were calculated by dividing weight by height and rounded to the nearest tenth as recommended by the original Quetelet calculation [19]. The resulting BMI categories were normal weight (BMI = 18.5 to 24.9 kg/m²), overweight (BMI = 25 to 29.9 kg/m²), and obese (BMI ≥ 30 kg/m²) [20]. Participants reported types of chronic conditions (i.e. cancer, respiratory disease, and other conditions) other than CVD&D. These were recorded and summed to create a continuous variable ranging from zero to three as non-CVD&D conditions. Participants were also asked to endorse their number of activities of daily living (ADL) limitations from a list of items pertaining to bathing, eating, dressing, and driving behaviors [21,22]. Endorsed ADL limitation items were summed to create a continuous variable ranging from zero to nine, where higher scores represent higher rates of ADL limitation. Respondents also rated depressive symptoms experienced in the past seven days on an 11-item version of the Center for Epidemiologic Studies Depression Scale (CES-D). Frequency of symptoms described in each item was rated on a four-point scale from “rarely or none of the time” (scored 1) to “most or all of the time” (scored 4). A total score for the 11 items was calculated, ranging from 11 to 44 (Cronbach’s α = 0.767) [23].

Health behaviors

Participants were asked to report their recent engagement in health-related behaviors. Respondents reported number of days they consume one or more alcoholic beverages in an average week (i.e. scored as a continuous variable from zero to seven). Respondents also reported the number of cigarettes they smoke in an average day. Responses were categorized as none, less than one pack (i.e. <20 cigarettes), and one pack or more (i.e. ≥20 cigarettes). Participants were also asked to report if they had sex in the previous year (yes or no).

Self-reported sexual dysfunctions

Participants were asked to report the occurrence of sexual dysfunctions within the previous year. Four sexual dysfunctions were listed, including lacking interest in having sex, being unable to climax, perceiving sex as not pleasurable, and having trouble getting or maintaining an erection. Responses were categorized as “yes” or “no.”

Sociodemographics

Personal characteristics of the participants included age groups (i.e. 57 to 64 years, 65 to 74 years, 75+ years), race/ethnicity (i.e. non-Hispanic white, nonwhite), highest education level achieved (i.e. graduate high school or less, more than a high school education), and marital status (yes or no).

Statistical analyses

All statistical analyses were performed using SPSS (version 17). Frequencies were calculated for all major study variables, which were initially examined in relationship to respondents’ chronic disease diagnoses (i.e. neither CVD nor diabetes, CVD only, and both CVD&D) and whether they ever discussed sex with a physician (yes or no). Pearson’s chi-square tests were performed to assess the independence between dependent variable and categorized independent variables. A one-way ANOVA was used to evaluate the mean differences among disease diagnosis categories for continuous variables. t-tests were used to examine mean differences for continuous variables based on patient–provider communication about sex. Multinomial logistic regression was used to identify personal characteristics, health indicators, health behaviors, and self-reported sexual dysfunctions associated with participants’ chronic disease diagnosis category (i.e. participants diagnosed with neither CVD nor diabetes served as the referent group). Logistic regression was then performed to identify risk factors associated with being diagnosed with both CVD and diabetes (i.e. being diagnosed with CVD-only served as the referent group). Another logistic regression was conducted to examine how sociodemographic characteristics, health indicators, health behaviors, self-reported sexual dysfunctions, and chronic disease diagnoses were associated with discussing sex with a physician since turning age 50 (i.e. not discussing sex with a physician served as the referent group).

Results

Sample

Sample characteristics of study participants are presented in Table I. Of the 1101 study participants, 36.7% were ages 57–64 years, 38.3% were 65–74 years, and 25.0% were 75 years and older. Respondents were disproportionately non-Hispanic white (75.4%), married (77.4%), and had more than a high school education (58.0%). Over 40% of the study population was overweight and an additional 37.8% were obese. Approximately 40% of participants had neither been diagnosed with CVD or diabetes, while 43.1% were diagnosed with CVD only and 17.0% were diagnosed with CVD&D. On average, participants reported having 1.08 (±0.83) chronic conditions types other than CVD&D. Study participants reported an average of 1.12 (±2.19) ADL limitations. Over 53% of participants reported being a current smoker, and on average, participants reported consuming one or more alcoholic beverages 1.96 (±2.54) days in an average week.

Table I.  Sample characteristics by disease diagnoses and discussing sex with a physician since turning age 50.

	Total (n = 1011)	Disease diagnoses					Discussed sex with a physician
		Neither CVD nor Diabetes (n = 403)	CVD Only (n = 436)	CVD & Diabetes (n = 172)	χ^2 or f	p	No (n = 626)	Yes (n = 385)	χ^2 or t	p
Age: 57 to 64 years	36.7%	43.9%	31.2%	33.7%	20.54	< 0.001	37.1%	36.1%	9.32	0.009
Age: 65 to 74 years	38.3%	35.0%	38.8%	44.8%			35.1%	43.4%
Age: 75+ years	25.0%	21.1%	30.0%	21.5%			27.8%	20.5%
Non-Hispanic white	75.4%	78.9%	75.8%	66.3%	10.34	0.006	73.1%	79.1%	4.60	0.032
Nonwhite	24.6%	21.1%	24.2%	33.7%			26.9%	20.9%
Education: high school or less	42.0%	39.0%	43.8%	44.8%	2.66	0.265	47.8%	32.7%	22.12	< 0.001
Education: more than high school	58.0%	61.0%	56.2%	55.2%			52.2%	67.3%
Single	22.6%	18.9%	27.1%	19.8%	8.99	0.011	23.0%	21.8%	0.19	0.662
Married	77.4%	81.1%	72.9%	80.2%			77.0%	78.2%
Body mass index: normal	22.0%	27.5%	20.0%	14.0%	36.43	< 0.001	24.9%	17.1%	9.31	0.010
Body mass index: overweight	40.3%	42.4%	42.0%	30.8%			37.7%	44.4%
Body mass index: obese	37.8%	30.0%	38.1%	55.2%			37.4%	38.4%
Number of non-CVD or diabetes diagnoses	1.08 (±0.83)	0.97 (±0.82)	1.17 (±0.84)	1.10 (±0.82)	6.26	0.002	0.96 (±0.83)	1.26 (±0.81)	32.44	< 0.001
Activities of daily living Limitations	1.12 (±2.19)	0.75 (±1.69)	1.19 (±2.30)	1.83 (±2.72)	15.13	< 0.001	1.19 (±2.31)	1.01 (±1.99)	1.51	0.219
Depression	4.63 (±4.54)	4.11 (±4.15)	4.86 (±4.72)	5.28 (±4.86)	4.98	0.007	4.71 (±4.67)	4.51 (±4.34)	0.46	0.498
Weekly alcohol consumption	1.96 (±2.54)	2.07 (±2.52)	2.14 (±2.70)	1.25 (±2.00)	8.24	< 0.001	1.88 (±2.50)	2.08 (±2.59)	1.55	0.213
Daily cigarettes smoked: none	46.5%	50.5%	42.5%	47.4%	6.17	0.187	48.4%	43.5%	2.56	0.278
Daily cigarettes smoked: less than 1 pack	17.7%	15.3%	19.9%	18.1%			17.5%	18.1%
Daily cigarettes smoked: 1 pack or more	35.8%	34.3%	37.6%	34.5%			34.1%	38.5%
Sex in past year: no	35.1%	27.9%	40.0%	39.9%	14.97	0.001	39.8%	27.5%	15.59	< 0.001
Sex in past year: yes	64.9%	72.1%	60.0%	60.1%			60.2%	72.5%
Lack of interest in having sex: no	83.2%	83.0%	84.0%	82.0%	0.38	0.829	84.9%	80.6%	3.08	0.079
Lack of interest in having sex: yes	16.8%	17.0%	16.0%	18.0%			15.1%	19.4%
Unable to climax: no	86.6%	87.7%	87.3%	82.6%	3.01	0.222	88.1%	84.2%	3.11	0.078
Unable to climax: yes	13.4%	12.3%	12.7%	17.4%			11.9%	15.8%
Sex is not pleasurable: no	96.5%	97.2%	95.6%	97.1%	1.86	0.395	97.1%	95.5%	1.60	0.206
Sex is not pleasurable: yes	3.5%	2.8%	4.4%	2.9%			2.9%	4.5%
Trouble getting or maintaining erections: no	75.2%	75.8%	78.0%	66.9%	8.25	0.016	82.0%	64.3%	39.21	< 0.001
Trouble getting or maintaining erections: yes	24.8%	24.2%	22.0%	33.1%			18.0%	35.7%
Number of sexual dysfunctions	0.95 (±1.40)	0.93 (±1.36)	0.90 (±1.40)	1.13 (±1.49)	1.61	0.200	0.79 (±1.30)	1.20 (±1.52)	19.76	< 0.001
Neither CVD nor diabetes diagnosis	39.9%	—	—	—	—	—	43.5%	34.0%	10.59	0.005
Diagnosed with CVD only	43.1%	—	—	—	—	—	41.7%	45.5%
Diagnosed with both CVD and diabetes	17.0%	—	—	—	—	—	14.9%	20.5%
Not discussed sex with a physician	61.9%	67.5%	59.9%	54.1%	10.59	0.005	—	—	—	—
Discussed sex with a physician	38.1%	32.5%	40.1%	45.9%			—	—	—	—

Approximately 65% of participants reported having sex in the previous year with an average of 0.95 (±1.40) sexual dysfunctions during that time period. Approximately 38% of participants reported discussing sex with a physician since turning age 50. Of those who experienced sexual dysfunction in the previous year, 24.8% reported having trouble getting or maintaining an erection, 16.8% reported having a lack of interest in having sex, and 13.4% reported being unable to climax. Fewer respondents (3.5%) reported sex was not pleasurable.

A significantly larger proportion of participants diagnosed with CVD only were age 75 years and older (χ² = 20.54, p < 0.001), whereas a larger proportion of those diagnosed with CVD&D were nonwhite (χ² = 10.34, p = 0.006). Compared to participants without CVD or diabetes diagnoses (30.0%), more participants with CVD only (38.2%) and CVD&D (55.2%) were also categorized as obese (χ² = 36.43, p < 0.001). On average, individuals with CVD&D reported significantly more ADL limitations (f = 15.13, p < 0.001) and depressive symptoms (f = 4.98, p = 0.007), compared to their counterparts without CVD or diabetes diagnoses. These individuals also reported significantly fewer days in which they consumed one or more alcoholic beverages in the average week (f = 8.24, p < 0.001). Furthermore, a significantly smaller proportion of those diagnosed with CVD only and CVD&D reported having sex within the past year (χ² = 14.97, p = 0.001) compared those without CVD or diabetes diagnoses, A larger proportion of those diagnosed with CVD&D reported having trouble getting or maintaining an erection (χ² = 8.25, p = 0.016). Respondents diagnosed with CVD only (40.1%) and CVD&D (45.9%) were also more likely to report ever having discussed sex with a physician since turning age 50 (χ² = 10.59, p = 0.005) than those without CVD or diabetes diagnoses (32.5%).

Factors associated with chronic disease diagnosis

Table II displays the results of the multinomial logistic regression analysis examining factors associated with participants’ disease diagnosis. The first model compared those who were diagnosed with CVD only to those without a CVD or diabetes diagnosis (i.e. the referent group). Participants who were age 75 years and older [OR = 1.90, CI (1.23, 2.93), p = 0.004], obese [OR = 2.06, CI (1.35, 3.14), p = 0.001], or less than 1-pack per day smokers [OR = 1.65, CI (1.08, 2.51), p = 0.019] were significantly more likely to be diagnosed with CVD compared to younger participants, those of normal weight, and nonsmokers, respectively. Married participants were significantly less likely to be diagnosed with CVD relative to their unmarried counterparts [OR = 0.67, CI (0.46, 0.99), p = 0.043]. For every additional ADL limitation reported, participants were 9% more likely to be diagnosed with CVD [CI (1.00, 1.19), p = 0.046].

Table II.  Correlates of disease diagnoses (n = 913).

	Diagnosed with CVD only						Diagnosed with both CVD and diabetes
	R	S.E.	p	OR	95% CI		R	S.E.	p	OR	95% CI
					Lower	Upper					Lower	Upper
Age: 75+ years	0.64	0.22	0.004	1.90	1.23	2.93	0.12	0.31	0.708	1.12	0.61	2.06
Age: 65 to 74 years	0.32	0.18	0.074	1.38	0.97	1.97	0.42	0.24	0.073	1.53	0.96	2.42
Age: 57 to 64 years	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Nonwhite	0.14	0.20	0.495	1.15	0.78	1.69	0.61	0.25	0.013	1.85	1.14	3.00
Non-Hispanic white	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Education: more than high school	0.02	0.16	0.895	1.02	0.74	1.41	0.13	0.22	0.534	1.14	0.75	1.75
Education: high school or less	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Married	−0.40	0.20	0.043	0.67	0.46	0.99	0.03	0.27	0.921	1.03	0.61	1.74
Single	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Body mass index: obese	0.72	0.21	0.001	2.06	1.35	3.14	1.16	0.30	< 0.001	3.20	1.79	5.70
Body mass index: overweight	0.36	0.20	0.072	1.44	0.97	2.14	0.37	0.30	0.222	1.45	0.80	2.61
Body mass index: normal	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Number of Non-CVD or diabetes diagnoses	0.14	0.10	0.165	1.15	0.95	1.39	0.08	0.13	0.525	1.09	0.84	1.40
Activities of daily living limitations	0.09	0.05	0.046	1.09	1.00	1.19	0.18	0.05	< 0.001	1.19	1.08	1.31
Depression	0.00	0.02	0.951	1.00	0.96	1.04	0.01	0.02	0.713	1.01	0.96	1.06
Weekly alcohol consumption	0.04	0.03	0.235	1.04	0.98	1.10	−0.10	0.05	0.029	0.90	0.83	0.99
Daily cigarettes smoked: 1 pack or more	0.27	0.17	0.110	1.31	0.94	1.83	−0.02	0.23	0.945	0.98	0.63	1.54
Daily cigarettes smoked: less than 1 pack	0.50	0.21	0.019	1.65	1.08	2.51	0.27	0.28	0.338	1.31	0.76	2.27
Daily cigarettes smoked: none	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Sex in past year: yes	−0.20	0.20	0.314	0.82	0.55	1.21	−0.69	0.28	0.014	0.50	0.29	0.87
Sex in past year: no	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Lack of interest in having sex: yes	0.06	0.23	0.788	1.06	0.68	1.66	0.03	0.29	0.911	1.03	0.58	1.84
Lack of interest in having sex: no	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Unable to climax: yes	0.12	0.26	0.657	1.12	0.67	1.87	0.26	0.32	0.411	1.30	0.69	2.44
Unable to climax: no	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Sex is not pleasurable: yes	0.71	0.46	0.118	2.04	0.83	4.99	0.03	0.61	0.961	1.03	0.31	3.40
Sex is not pleasurable: no	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Trouble getting or maintaining erections: yes	−0.16	0.22	0.451	0.85	0.55	1.30	0.71	0.28	0.012	2.04	1.17	3.55
Trouble getting or maintaining erections: no	1.00	—	—	—	—	—	1.00	—	—	—	—	—
Referent group: neither CVD nor diabetes diagnoses

The second model compared those who were diagnosed with both CVD and diabetes (CVD&D) to those without either diagnoses. Nonwhite participants [OR = 1.85, CI (1.14, 3.00), p = 0.013] and those who were obese [OR = 3.20, CI (1.79, 5.70), p < 0.001] were significantly more likely to be diagnosed with CVD&D compared to non-Hispanic whites and those of normal weight, respectively. For every additional ADL limitation reported, participants were 19% more likely to be diagnosed with CVD&D [CI (1.08, 1.31), p < 0.001]. In contrast, for every additional day per week alcoholic beverages were consumed, participants were 10% less likely to be diagnosed with CVD&D [CI (0.83, 0.99), p = 0.029]. Participants who reported having sex in the previous year were significantly less likely to be diagnosed with CVD&D compared to those who did not have sex [OR = 0.50, CI (0.29, 0.87), p = 0.014]. Conversely, participants who reported having trouble getting or maintaining an erection were significantly more likely to be diagnosed with CVD&D compared to those without this sexual problem [OR = 2.04, CI (1.17, 3.55), p = 0.012].

Comparisons between being diagnosed with CVD only and both CVD and diabetes

Table III displays the results of the logistic regression analysis that omitted participants diagnosed with neither CVD nor diabetes and examined the factors associated with being diagnosed with both CVD and diabetes (i.e. CVD-only diagnosis served as the referent group). Participants age 75 years and older were significantly more likely to be diagnosed with CVD&D compared to younger participants [OR = 1.77, CI (1.04, 3.00), p = 0.035]. Nonwhite participants were significantly more likely to be diagnosed with CVD&D compared to non-Hispanic whites [OR = 1.71, CI (1.06, 2.76), p = 0.029]. For every additional ADL limitation reported, participants were 10% more likely to be diagnosed with CVD&D [CI (1.01, 1.19), p = 0.029]. For every additional day per week alcoholic beverages were consumed, participants were 12% less likely to be diagnosed with CVD&D [CI (0.80, 0.96), p = 0.004]. Participants who reported having trouble getting or maintaining an erection were significantly more likely to be diagnosed with CVD&D and diabetes compared to those without this sexual problem [OR = 2.36, CI (1.33, 4.17), p = 0.003].

Table III.  Correlates of both CVD and diabetes diagnoses (n = 549).

	χ	S.E.	p	OR	95% CI
					Lower	Upper
Age: 57 to 64 years	1	—	—	—	—	—
Age: 65 to 74 years	0.45	0.31	0.149	1.56	0.85	2.87
Age: 75+ years	0.57	0.27	0.035	1.77	1.04	3
Non-Hispanic white	1	—	—	—	—	—
Nonwhite	0.54	0.25	0.029	1.71	1.06	2.76
Education: high school or less	1	—	—	—	—	—
Education: more than high school	0.08	0.21	0.706	1.08	0.71	1.65
Single	1	—	—	—	—	—
Married	0.45	0.26	0.083	1.57	0.94	2.6
Body mass index: normal	1	—	—	—	—	—
Body mass index: overweight	−0.46	0.3	0.12	0.63	0.35	1.13
Body mass index: obese	−0.41	0.23	0.07	0.66	0.43	1.03
Number of non-CVD or diabetes diagnoses	−0.06	0.13	0.65	0.94	0.73	1.21
Activities of daily living limitations	0.09	0.04	0.029	1.1	1.01	1.19
Depression	0.01	0.02	0.621	1.01	0.97	1.06
Weekly alcohol consumption	−0.13	0.05	0.004	0.88	0.8	0.96
Daily cigarettes smoked: none	1	—	—	—	—	—
Daily cigarettes smoked: less than 1 pack	0.27	0.23	0.228	1.31	0.84	2.04
Daily cigarettes smoked: 1 pack or more	0.04	0.29	0.893	1.04	0.59	1.82
Sex in past year: no	1	—	—	—	—	—
Sex in past year: yes	−0.52	0.28	0.06	0.59	0.35	1.02
Lack of interest in having sex: no	1	—	—	—	—	—
Lack of interest in having sex: yes	0.06	0.3	0.838	1.06	0.59	1.91
Unable to climax: no	1	—	—	—	—	—
Unable to climax: yes	0.22	0.33	0.493	1.25	0.66	2.37
Sex is not pleasurable: no	1	—	—	—	—	—
Sex is not pleasurable: yes	−0.72	0.58	0.217	0.49	0.16	1.53
Trouble getting or maintaining erections: no	1	—	—	—	—	—
Trouble getting or maintaining erections: yes	0.86	0.29	0.003	2.36	1.33	4.17
Referent group: diagnosed with CVD only

Factors associated with discussing sex with a physician

As seen in the bivariate analyses presented in Table I, significant differences were identified based on whether or not the participant discussed sex with a physician since turning age 50. Compared to those who had not discussed sex with a physician, a significantly larger proportion of those between the ages of 65 and 74 years and a significantly smaller proportion of those age 75 and older reported discussing sex with a physician (χ² = 9.32, p = 0.009). A significantly larger proportion of those who discussed sex with a physician had more than high school education (χ² = 22.12, p < 0.001), whereas a smaller proportion was nonwhite (χ² = 4.60, p = 0.032). Compared to those who had not discussed sex with a physician, a significantly larger proportion of overweight participants and a significantly smaller proportion of obese participants reported discussing sex with a physician since turning age 50 (χ² = 9.31, p = 0.010). On average, participants who discussed sex with a physician reported significantly more chronic condition types beyond CVD&D (t = 32.44, p < 0.001). A significantly larger proportion of participants who reported discussing sex with a physician also reported having sex within the past year (χ² = 15.59, p < 0.001). On average, those discussing sex with a physician reported significantly more sexual dysfunctions (t = 19.76, p < 0.001), specifically trouble getting and maintaining an erection (χ² = 39.21, p < 0.001).

Table IV displays the results of the logistic regression analysis explaining factors associated with participants ever discussing sex with a physician (i.e. not discussing sex with a physician served as the referent group). Participants with more than high school education were significantly more likely to have discussed sex with a physician relative to their less educated counterparts [OR = 1.68, CI (1.23, 2.28), p = 0.001]. Compared to participants diagnosed with neither CVD nor diabetes, those diagnosed with CVD only were significantly less likely to have discussed sex with a physician [OR = 0.54, CI (0.36, 0.82), p = 0.004]. For each additional chronic condition type diagnosis (other than CVD or diabetes), participants were 62% more likely to discuss sex with a physician [CI (1.35, 1.96), p < 0.001], as were those who reported having sex in the previous year [OR = 1.73, CI (1.17, 2.57), p = 0.006] or trouble getting or maintaining an erection [OR = 2.26, CI (1.51, 3.38), p < 0.001].

Table IV.  Correlates associated with discussing sex with a physician since turning age 50 (n = 913).

	χ	S.E.	p	OR	95% CI
					Lower	Upper
Age: 57 to 64 years	1	—	—	—	—	—
Age: 65 to 74 years	0.19	0.22	0.387	1.21	0.79	1.86
Age: 75+ years	0.35	0.2	0.078	1.42	0.96	2.09
Non-Hispanic white	1	—	—	—	—	—
Nonwhite	0.02	0.19	0.926	1.02	0.7	1.48
Education: high school or less	1	—	—	—	—	—
Education: more than high school	0.52	0.16	0.001	1.68	1.23	2.28
Single	1	—	—	—	—	—
Married	−0.29	0.19	0.123	0.75	0.52	1.08
Body mass index: normal	1	—	—	—	—	—
Body mass index: overweight	−0.23	0.21	0.285	0.8	0.53	1.21
Body mass index: obese	0.19	0.17	0.246	1.21	0.88	1.68
Neither CVD nor diabetes diagnosis	1	—	—	—	—	—
Diagnosed with CVD only	−0.61	0.21	0.004	0.54	0.36	0.82
Diagnosed with both CVD and diabetes	−0.27	0.21	0.197	0.77	0.51	1.15
Number of non-CVD or diabetes diagnoses	0.49	0.1	< 0.001	1.62	1.35	1.96
Activities of daily living limitations	−0.02	0.04	0.695	0.99	0.92	1.06
Depression	0	0.02	0.953	1	0.97	1.04
Weekly alcohol consumption	0.02	0.03	0.485	1.02	0.96	1.08
Daily cigarettes smoked: none	1	—	—	—	—	—
Daily cigarettes smoked: less than 1 pack	−0.15	0.16	0.364	0.86	0.63	1.19
Daily cigarettes smoked: 1 pack or more	−0.17	0.21	0.424	0.85	0.56	1.28
Sex in past year: no	1	—	—	—	—	—
Sex in past year: yes	0.55	0.2	0.006	1.73	1.17	2.57
Lack of interest in having sex: no	1	—	—	—	—	—
Lack of interest in having sex: yes	−0.09	0.21	0.68	0.92	0.6	1.39
Unable to climax: no	1	—	—	—	—	—
Unable to climax: yes	−0.43	0.25	0.078	0.65	0.4	1.05
Sex is not pleasurable: no	1	—	—	—	—	—
Sex is not pleasurable: yes	−0.14	0.42	0.743	0.87	0.38	1.99
Trouble getting or maintaining erections: no	1	—	—	—	—	—
Trouble getting or maintaining erections: yes	0.82	0.21	< 0.001	2.26	1.51	3.38
Referent group: not discussing sex with a physician

Discussion

NSHAP data has been used to explore a variety of health issues among the aging, including sexual health [16]. However, this study is the first to use NSHAP data in exploring sexual behaviors, problems, and communication with healthcare providers among older males with chronic health conditions. Men diagnosed with CVD or CVD&D in this sample were more likely to be obese and have limitations on their ability to participate in activities of daily living (e.g. bathing, dressing) compared to their counterparts without such limitations. Those with CVD&D were less likely to report having sex within the previous year and more likely to report erectile dysfunction (ED) than healthier males. When men with CVD only and those with CVD&D were compared directly, men with CVD&D were older and had greater difficulty with activities of daily living and achieving and maintaining erections. A substantial number of participants were affected by chronic diseases requiring routine medical care (60.1%) and reported not having sex in the past year (35.1%), yet only 38.1% reported ever discussing sexual concerns with a physician since turning age 50. Those reporting such discussions with physicians were more likely to have higher educational attainment and more comorbidities (i.e. CVD&D and a number of non-CVD or diabetes diagnoses). They were also more likely to report having sex within the previous year, but with more trouble achieving and maintaining erections.

Given that middle-age men with ED are at elevated risk for developing CVD and diabetes, integrating risk-factor assessment and ED treatment represents an opportunity for disease prevention [13,24]. Many of these men are still employed and not yet eligible for Medicare or experiencing severe morbidities and activity limitations. Activating health-promoting attitudes and behaviors, including access to healthcare services, at this primary prevention stage may prevent or forestall the more serious sequelae of CVD and diabetes. A number of studies have examined the issue of aging and sexuality among male participants and found strong relationships between ED and decrements in sexual satisfaction and quality of life [11,13,25]. Men with CVD only or CVD&D engaging in sexual activity and experiencing sexual dysfunction may go to the physician expressly for the purpose of obtaining ED treatment, with varying results. Kriston and colleagues (2010) showed males with CVD who receive ED treatment may experience improvements in their sexual functioning [7]; however, male patients with ED may change medications multiple times or discontinue treatment prior to finding the most effective drug for them [26–28]. This process may be particularly frustrating for men whose ED treatment options are limited because of potential interactions with CVD or diabetes medication. Findings from the current study emphasize the need for practice and research efforts that facilitate sexual functioning as a component of healthy aging. Such health promotion efforts should span the disease prevention continuum, and include regular interactions with healthcare professionals [29] and multiple treatment modalities. Strategies to increase screening and treatment may include healthy aging campaigns raising awareness of the relationship between ED and cardiovascular and diabetes risk and referral to private physicians or community-based clinics.

Practice implications

The complexities of treating comorbidities and addressing sexual health issues among this population require integrating public health and primary care to produce a true continuum of patient care. Although service coordination may focus on primary prevention, it should also increase provider training in geriatric medicine. Studies such as those by Mas and colleagues provide evidence that brief, structured educational interventions can improve providers’ knowledge and self-efficacy related to CVD risk assessment and disease management [30]. Further training should also strive to increase providers’ awareness of ED as a risk factor CVD and diabetes, and raise awareness about risk assessment algorithms and tests (i.e. performing a holistic assessment) [12,31,32]. Continuing education should also focus on improving physicians’ sexual history taking skills and communication, which are critical to managing sexual problems [33]. Older patients who believe their physicians are addressing their disease-specific and sexual concerns may respond positively to such patient–provider discussions, resulting in increased participation in diagnostic testing and treatment [34].

Treatment of complex patients with multiple chronic conditions requires physicians to constantly monitor patients’ disease progression, prescription medications regimens, and associated side effects. Thus, there is also a need for continuing education to increase provider awareness about potential interactions between CVD or diabetes treatment and drugs used to decrease sexual dysfunction. Additional efforts should focus on disseminating evidence-based information that guides physicians in prescribing the most effective CVD or diabetes drugs with the smallest disease-specific and sexual side effect profile. Such patient-centered interventions have potential to improve patients’ sexual health quality and reduce associated frustration.

Communication is a critical component of the patient–provider relationship and patient-centered care. Politi and Street [35] offer strategies that will enhance patient–provider communication and collaborative decision making. Such strategies include providing clear explanations concerning the nature of the patient’s illness and treatment options; confirming patient’s comprehension of information; eliciting patient’s values, concerns, and needs in terms of their condition, treatment options, and alignment with their family of origin or culture; finding common ground related to the patient’s and provider’s treatment goals; reaching consensus on a treatment plan; and establishing a mutually acceptable follow-up plan. Using this model, improves the likelihood that patients will take a more active role in determining their treatment plan and participating in necessary follow-up with their primary care physicians and allied health professionals.

Improved referral systems between primary care physicians and allied health professionals (e.g. nutritionists, sexual counselors/therapists, marital and family therapists, and physical therapists) are required to ensure seamless treatment plans. While primary care physicians provide the “medical home,” they should also recognize the importance of comprehensive public health approaches to change lifestyle behaviors when treating individuals with CVD or CVD&D. Provider referrals to allied health professionals will facilitate treatment plans tailored to individual patient’s physical and mental health needs. For example, smoking cessation may be recommended for a number of patients because of its multifaceted impact on CVD, diabetes, and ED. However, smoking cessation efforts may be jointly treated by primary care and mental health as research has demonstrated that patients receiving pharmacotherapy and counseling have better smoking abstinence rates [36]. Involving sexual and marital partners into ED treatment may improve patients’ treatment-seeking and adherence to ED therapy [37]. Men taking phosphodiesterase 5-inhibitors (e.g. sildenafil) who positive increases in satisfaction with erection quality and hardness are significantly more likely to report increased emotional well-being, relationship satisfaction, and satisfaction with ED treatment than men on placebo [38]. The net result may be reductions in disabilities associated with CVD and diabetes and increases in patients’ health-related quality of life.

Limitations

There were several limitations associated with this study. First, all data pertaining to chronic disease diagnoses and interactions with physicians were self-reported, thus bias might be introduced. Second, the cross-sectional nature of these data limited our ability to infer causality concerning study relationships. For example, we were unable to ascertain the directionality of the patient–physician interaction about sexual health issues. It is conceivable the participant experienced symptoms associated with sexual dysfunction prior to the clinic visit; however, it is also possible the patient became aware of their sexual dysfunction during a regular physician visit for CVD and/or diabetes testing. The topics discussed during physician visits were not collected and it is unknown whether or not patient–physician interactions yielded prescriptions for ED medication. Further, it is unknown whether the ED and other sexual issues preceded or resulted from CVD only or CVD&D, or some combination. Additionally, this study included no information pertaining to participants’ satisfaction with the frequency or quality of their sexual interactions. While some men may view sexual dysfunction as a mild inconvenience, others may perceive it to be a major concern. Further, some men may not be distressed by their loss of sexual functioning in light of being diagnosed with health conditions they perceive to be more clinically severe.

Conclusion

Given that studies on male aging have traditionally focused on morbidity and mortality, additional studies are needed to explore aspects of healthy, successful aging. While implications for this study indicate the need for coordinated diagnosis and treatment efforts for sexual dysfunction among patients with comorbidities, healthcare providers are encouraged to perceive erectile dysfunction as a symptom of more serious chronic conditions. Effective patient–provider communication and collaborative interactions are critical elements to promote a more comprehensive perspective of healthy aging among males with cardiovascular disease and/or diabetes. Integrated public health and primary care interventions are needed to modify lifestyle behaviors, promote self-care practices, and improve healthcare utilization among male patients suffering from chronic disease.

Declaration of Interest: Supported in part by the Houston VA HSR&D Center of Excellence (HFP90-020) and a National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health – K12-DK08301 (Lamb). The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs.