November/December 2024

November/December 2024 Issue

Stemming the Spread of Syphilis
By Mark D. Coggins, PharmD, BCGP, FASCP
Today’s Geriatric Medicine
Vol. 17 No. 6 P. 10

Rates of infection are soaring, and the need for awareness, education, and assessment is urgent.

Despite misconceptions about the diminished sexual activity of older adults, it’s crucial to acknowledge that older patients are indeed sexually active and remain susceptible to acquiring sexually transmitted diseases (STDs). In fact, the rates of STDs, including syphilis, in older adults have been on the rise in recent years, with the number of syphilis cases more than doubling in adults aged 55 and older from 2018 to 2022.1

This trend raises concerns about inadequate awareness of syphilis and other STDs both among older adults and health care professionals who serve this demographic.

The lack of knowledge about symptoms and risk factors for syphilis in older adults could lead to delayed diagnosis and treatment, with potentially serious health complications. Therefore, there’s an urgent need to address the factors contributing to the rise of STDs among this age group, break down societal taboos and stigma associated with sexual health, and provide comprehensive education and prevention strategies to protect the well-being of this population.

This may be achieved through steps such as targeted screening programs and educating older adult populations about the risks of syphilis and the importance of regular testing. In addition, health care professionals should be knowledgeable about the signs and symptoms of syphilis in older adults and be prepared to provide appropriate care and treatment. Failure to urgently address this issue may have detrimental consequences for current and future generations of older adults.

What Is Syphilis?
Syphilis, a preventable and curable STD, is caused by the spirochete Treponema pallidum bacteria and can have serious health consequences if left untreated. Syphilis is primarily contracted through sexual intercourse, requiring contact with moist skin or mucous membrane lesions. It can also be transmitted by blood transfusions and from an infected mother to her baby during pregnancy and childbirth if the infant comes into direct contact with a syphilis sore.

Historical Perspective
Syphilis has a long history and intertwines with human history, culture, and society. It’s been associated with well-known figures and has influenced art and literature as well as public health policies and attitudes toward sexuality and morality throughout the centuries. Some believe the disease was brought to Europe from the Americas by Christopher Columbus and his crew.2,3 The first known outbreak was documented in 1495 among French soldiers besieging Naples during the Italian Wars and was initially called the “French disease.”2,3 From the outset, syphilis has been a disease associated with shame and stigma. The illness spread to other regions and continents, causing widespread devastation with a tendency to blame neighboring (and sometimes adversarial) countries for its spread. The term syphilis was created by the Italian physician and poet Girolamo Fracastoro in his 1530 epic poem “Syphilis sive morbus Gallicus,” in which he vividly portrayed the relentless and devastating effects of this enigmatic and highly contagious illness, named after the mythical shepherd-boy Syphilus, who was cursed by the god Apollo with a terrible venereal disease.3

Current Trends
In the early 20th century, syphilis was a significant cause of illness and death, leading to the development of public health interventions and treatment programs, but the disease persists today. Globally, cases have escalated by more than one million in 2022, reaching eight million.4 The United States now faces the highest incidence worldwide, with 3.37 million cases (or 6.5 cases per 1,000 people), accounting for 42% of all new cases.4 There’s also been a surge in the incidence of syphilis in older adults, increasing seven-fold and 8.6-fold in those older than 55 and 65 years of age, respectively, from 2012 to 2022.1

Clinical Presentation
Syphilis can affect virtually every organ system in the body, even many years or decades after the original infection. The clinical presentation of syphilis in older adults may include diverse symptoms such as skin rashes, joint pain, neurological manifestations, cardiovascular complications, and auditory and visual symptoms.

Stages of Progression
Syphilis infection progresses through four stages.

Primary Stage
The primary stage begins 10 to 90 days after infection, the disease typically manifesting as one or more firm, circular, painless sores, known as chancres, at the infection site—typically the genitals, anus, lips, or mouth. Because of the lack of pain, the sores often go unnoticed and untreated, allowing the disease to progress to the secondary stage. These highly contagious sores may last three to six weeks before healing, even without treatment.

Secondary Stage
Without treatment, syphilis can progress to the secondary stage, which occurs when the bacterium multiplies and spreads throughout the body. This stage typically begins two to eight weeks after the appearance of the initial sore and is characterized by skin rashes and mucous membrane lesions. The initial chancre usually heals by the time the secondary stage develops and is frequently not remembered by the patient. The secondary stage rash usually does not cause itching and may appear as rough, red, or reddish-brown spots on the palms of the hands (palmer rash) and the bottoms of the feet (plantar rash). Palmer and plantar rash are highly suggestive of syphilis and require further evaluation. Other symptoms may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. These symptoms may disappear with or without treatment, but the infection remains.

Latent Stage
The absence of symptoms characterizes the latent or “clinically silent stage,” although the bacteria remain in the body. The bacteria are detectable only through testing and can last for years. Latent syphilis acquired within the preceding year is referred to as early latent syphilis; all other cases of latent syphilis are classified as late latent syphilis or latent syphilis of unknown duration. The diagnosis of latent syphilis is made when serologic tests are reactive without other evidence of disease.

Tertiary Stage
If syphilis is untreated, approximately 15% of infected individuals will progress to the tertiary stage. This stage can occur 10 to 30 years after initial infection. While individuals are not contagious during this stage, over time, the bacteria can cause severe damage to the body, including neurological and brain diseases, cardiovascular diseases, soft masses on the skin or internal organs such as bone or the liver, and increased risk of HIV infection as syphilis can cause bleeding sores around the genitals and mouth.

Other Severe Complications
T. pallidum can cause severe complications that can occur during any stage by infecting the central nervous system (neurosyphilis), visual system (ocular syphilis), and auditory system (otosyphilis).

Neurosyphilis
Infection of the central nervous system can occur at any stage of syphilis and result in neurosyphilis. Early neurologic clinical manifestations or syphilitic meningitis (eg, cranial nerve dysfunction, meningitis, meningovascular syphilis, stroke, and acute altered mental status) are usually present within the first few months or years of infection. Late neurological complications (such as tabes dorsalis, general paresis, cranial nerve dysfunction, meningitis, meningovascular syphilis, stroke, and acute altered mental status) may occur 10 to more than 30 years after infection.

Ocular Syphilis
Infection of the visual system (ocular syphilis) may present with or without additional central nervous system involvement. Ocular syphilis often presents as panuveitis but can involve structures in both the anterior and posterior segment of the eye, including conjunctivitis, anterior uveitis, posterior interstitial keratitis, optic neuropathy, and retinal vasculitis. Ocular syphilis can result in permanent vision loss.

Otosyphilis
Otosyphilis typically presents with cochleovestibular symptoms, including tinnitus, vertigo, and sensorineural hearing loss. Hearing loss can be unilateral or bilateral, with a sudden onset and rapid progression, and can result in permanent hearing loss.

Diagnosis
The potential for misdiagnosis of syphilis in older adults is heightened due to frequent nonspecific symptoms that overlap with other age-related conditions and a lack of awareness among health care professionals about syphilis in this age group. Therefore, health care providers need to consider syphilis as a potential diagnosis in older adults presenting with vague symptoms. Diagnosis typically relies on clinical symptoms and various laboratory tests, such as blood tests, cerebrospinal fluid analysis, and tissue samples. A positive diagnosis necessitates that sexual partners also undergo testing and treatment to avert the possibility of reinfection.

Treatment
Syphilis is curable, especially in its early stages, with appropriate antibiotics. Penicillin G benzathine injectable suspension (long-acting formulation) is the preferred drug for treating patients in all stages. The dose and duration of treatment depend on the stage of the disease. In the early stages, a single dose of penicillin may be sufficient to cure the infection. However, a longer course of antibiotics may be necessary in later stages to fully eradicate the bacteria from the body. Treatment for late latent syphilis (lasting more than one year) and tertiary syphilis requires a longer duration of therapy. This is true, as well, for persons with latent syphilis of unknown duration to ensure that those who did not acquire syphilis within the preceding year are adequately treated. Whenever possible, patients with syphilis who have a penicillin allergy should be desensitized and treated with penicillin, as other antibiotics are considered to be less effective. If necessary, doxycycline and tetracycline may be treatment options.

Factors Increasing the Risk in Older Adults
Understanding the factors that increase the risk of syphilis in older adults can help in developing targeted interventions.

Misconceptions
Intimacy and sexual activity play a crucial role in promoting health and wellbeing and are associated with increased life satisfaction and wellness among older individuals. It’s a misconception that people become asexual as they age, although they may adjust their sexual activity due to physiological changes. The failure to address sexual health in older adults can lead to poor outcomes, such as increased risk of STDs like syphilis.

Increased Life Expectancy
Older adults are living longer and maintaining active lifestyles, including sexual activity, much later in life than they did previously. A survey from the National Poll on Healthy Aging revealed that 40% of individuals aged 65 to 80 are sexually active.5 Nearly 72% of individuals in that age range have a romantic partner, and of those, 54% are sexually active.

Advances in Medicine
Physical changes such as menopause in women and erectile dysfunction in men may have once hindered sexual activity in some older adults. However, treatments such as hormone replacement therapy and erectile dysfunction medications are enabling older adults to remain sexually active for more extended periods, so age does not necessarily preclude the enjoyment of a healthy sex life.

Lack of Sexual Health Education
Many older adults may not have received comprehensive sex education, leading to a lack of awareness about STD prevention and transmission.

Underestimation of Risk
Pregnancy is no longer a concern in postmenopausal women. However, there’s a tendency among older adults to underestimate their risk of STDs, which can result in not taking necessary precautions like using condoms.

Changes in Relationship Status
Life events such as divorce or the death of a spouse can lead to new sexual partnerships without adequate knowledge of STD prevention.

Social Changes
With more older adults living in community settings like assisted living facilities, there are increased opportunities for new sexual encounters. Also, older people are now using online dating apps and have increased likelihood of sexual interactions with partners they’re less familiar with and unaware of their sexual histories.

Symptoms Overlooked
STD symptoms in older adults may be mistaken for other age-related conditions, leading to underdiagnosis and untreated infections.

Lack of Screening and Prevention
There is a lack of targeted STD screening and prevention resources for the older population, which could help in early detection and education.

The Role of Health Care Professionals
Health care professionals can play a pivotal role in addressing the rise of syphilis among older adults by implementing new strategies focused on them.

Increased Health Care Provider Training
Health care providers also should be trained to regularly take a sexual history and assess the sexual health needs of older adults, providing comprehensive sexual health services as part of routine care.

Public Health Initiatives and Education
Public health initiatives should prioritize awareness of STDs and target outreach efforts to educate older adults about risks and prevention methods.

Improved Communication
Communication is vital, and health care professionals must help destigmatize the topic of sexual health to encourage older patients to be more forthright about their sexual histories and practices. Health care settings should be safe spaces where patients feel comfortable discussing their sexual health without judgment or stigma.

STD Screening/Treatment
More targeted STD screening and prevention resources for the older population must be created, which could help in early detection and education. Screening older adults at high risk is essential, as is improving the increased availability of testing and treatment services. Increased testing opportunities include offering testing during routine health visits and ensuring that treatment is accessible and affordable. Additionally, the introduction of over-the-counter syphilis tests may benefit older adults by allowing them to stay informed about their status from the comfort of their homes. These tests can serve as a preliminary screening tool, which should be followed by professional medical confirmation if a positive result is obtained.

In a Nutshell
Syphilis is a serious health concern that’s preventable and curable, but reversing the increased trend of syphilis in older adults will require that health care providers prioritization of the issue in older adults. It’s essential that they educate themselves and others about syphilis in the aging population, and older adults need to be aware of the need to practice safe sex and use barrier methods, such as condoms, which are essential to reducing the risk of contracting or spreading the infection. With proper medical care and prevention measures, the spread of syphilis can be minimized, and its impact on individuals and communities can be reduced.

— Mark D. Coggins, PharmD, BCGP, FASCP, is a long term care expert and corporate pharmacy consultant for Touchstone-Communities, a leading provider of senior care that include skilled nursing care, memory care, and rehabilitation for older adults throughout Texas. He’s a past director of the American Society of Consultant Pharmacists and was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the Excellence in Geriatric Pharmacy Practice Award.

References
1. CDC’s 2022 STI Surveillance Report underscores that STIs must be a public health priority. Centers for Disease Control and Prevention website. https://www.cdc.gov/std/statistics/2022/. Updated January 30, 2024. Accessed September 6, 2024,

2. Frith J. Syphilis — its early history and treatment until penicillin, and the debate on its origins. J Mil Veterans Health. 2012;20(4):49-58.

3. Tampa M, Sarbu I, Matei C, Benea V, Georgescu SR. Brief history of syphilis. J Med Life. 2014;7(1):4-10.

4. Implementing the global health sector strategies on HIV, viral hepatitis and sexually transmitted infections, 2022–2030: report on progress and gaps 2024. Geneva: World Health Organization; 2024.

5. University of Michigan. Sex after 65: poll of older adults finds links to health, gender differences, lack of communication with doctors. www.healthyagingpoll.org/sites/default/files/2018-06/NPHA%2C%20May%202018%20Report.pdf. Published May 3, 2018.