What is the incidence and prevalence of syphilis in older adults?

Recent data from commercial health insurance claims in the U.S. showed that diagnoses for syphilis soared nearly tenfold in people aged 65 and older from 2010 to 2023. Understanding what is the incidence and prevalence of syphilis in older adults is crucial as these rates continue to rise globally, highlighting a significant and often overlooked public health issue. This trend is linked to a lack of awareness, reduced condom use, and increased sexual activity among older populations, necessitating greater attention to sexual health in geriatrics.

Quick Summary

Syphilis incidence and prevalence are increasing among older adults, a trend observed in multiple countries. Factors like less condom use and provider assumptions contribute to this rise. Older adults are also more likely to present with late-stage syphilis.

Key Points

• Rising Trend: The incidence and prevalence of syphilis in older adults are increasing, with cases among those 65 and older soaring in some regions.

• Causes of Increase: Factors like decreased condom use (due to no pregnancy risk), increased access to ED medications, and a lack of awareness contribute to the rise.

• Late-Stage Diagnosis: Older adults are more likely to be diagnosed with late-stage or latent syphilis, potentially due to symptoms being misattributed to other age-related conditions.

• Healthcare Gap: Healthcare providers often overlook sexual health history in older patients, creating a screening gap and contributing to delayed diagnosis.

• Intervention Needed: Addressing this trend requires increased screening, provider education, and public awareness campaigns to normalize sexual health discussions in this demographic.

• Global Concern: Rising rates have been documented in multiple countries, including the U.S., China, and Japan, indicating a global public health issue.

The Resurgence of Syphilis in Older Populations

The rising incidence and prevalence of sexually transmitted infections (STIs) among older adults is a growing public health concern worldwide, with syphilis representing a particularly notable increase. Historically, STIs have been largely associated with younger populations, leading to a misconception that older adults are not at risk. However, recent data demonstrates that this is no longer the case, driven by factors including increased sexual longevity, less consistent condom use, and a general lack of sexual health education for seniors. This phenomenon challenges preconceived notions and highlights the need for targeted public health interventions.

Documented Trends in Syphilis Incidence and Prevalence

Research from different countries provides a clear picture of the rising burden of syphilis among older adults:

• United States: A Fair Health study using commercial health insurance claims from 2020 to 2023 reported a 23.8% surge in STD diagnoses among those 65 and older, with syphilis cases in this demographic increasing nearly tenfold since 2010.
• China: A 16-year study (2004–2019) in Guangdong, China, found that the annual notification rate for new syphilis diagnoses among older adults ($\ge$50 years) significantly increased, with a mean rate of 64.1 per 100,000 population over the study period.
• Japan: A nationwide observational study from 2009 to 2019 reported an eightfold increase in total syphilis cases among people aged 50 and older. Age-adjusted incidence rates surged significantly in both men and women in this age group.

Why are Syphilis Rates Increasing Among Older Adults?

Several factors contribute to the rising rates of syphilis among older adults, distinct from the risk factors often cited for younger generations:

• Reduced Barrier Protection: Unlike younger cohorts, older adults are not concerned about pregnancy, which can lead to a decrease in condom use. This significantly increases the risk of acquiring and transmitting STIs.
• Erectile Dysfunction (ED) Treatments: The widespread availability and use of treatments like sildenafil (Viagra) have contributed to extended sexual activity for many older adults, potentially increasing exposure time and partners.
• Lack of Awareness and Stigma: Many older adults and healthcare providers may not associate STIs with this age group. This lack of awareness and potential shame can lead to inadequate screening, delayed diagnosis, and missed opportunities for prevention.
• Healthcare Provider Assumptions: Healthcare professionals often overlook sexual health history when treating older patients, which means syphilis symptoms can be misinterpreted or missed. As a result, older patients are more likely to be diagnosed in the later, more serious stages of the disease.
• Changing Relationship Dynamics: The sexual health landscape for older adults has shifted due to factors like higher divorce rates and increased access to online dating, leading to more partners and increased potential exposure.

Clinical Presentation and Stages in Older Adults

Syphilis can be more challenging to diagnose in older adults. While primary syphilis symptoms (like chancres) are less common in this population, late-stage symptoms that can mimic other age-related conditions are more prevalent.

Comparison of Syphilis Presentation: Young vs. Older Adults

Feature	Younger Adults (e.g., 15-49 years)	Older Adults (e.g., ≥50 years)
Stage at Diagnosis	Often diagnosed in primary or secondary stages.	Higher proportion of latent and tertiary stage diagnoses.
Primary Chancre	More common and frequently observed.	Less common to present with a primary chancre.
Symptom Misinterpretation	Symptoms are often recognized as STI-related.	Symptoms may be misdiagnosed as other neurological or age-related issues (e.g., cognitive decline, neuropathy, stroke).
Neurosyphilis	Can occur, but may be diagnosed earlier.	Seropositivity has been demonstrated in older adults with unexplained neurological symptoms, suggesting a potential link to tertiary syphilis.

Public Health Implications and Recommendations

The rising incidence of syphilis in older adults necessitates a more proactive approach to sexual health in this demographic. Public health efforts should include:

• Increased Screening: Routine screening for STIs, including syphilis, should be integrated into primary care for older adults, particularly for those with new partners or multiple partners.
• Provider Education: Health care providers must be educated on the unique aspects of syphilis in older adults, including the varied clinical presentations and the importance of a comprehensive sexual history.
• Public Awareness Campaigns: Educational campaigns specifically targeting older populations are needed to raise awareness about the risk of STIs and the importance of prevention, including consistent condom use.
• Integrated Care: Integrating syphilis screening and prevention services into broader primary care for older adults can help normalize the conversation around sexual health and improve detection rates.

Conclusion

The incidence and prevalence of syphilis in older adults are rising, representing a significant public health challenge that has been largely overlooked. Older adults, for reasons related to sexual activity changes, a decline in consistent condom use, and healthcare provider assumptions, are now a growing risk population. Research from the U.S., China, Japan, and other regions confirms this upward trend, with many older adults being diagnosed with late-stage or latent syphilis. The issue underscores a critical need for targeted interventions, improved screening protocols, and destigmatizing sexual health conversations among the elderly. By taking these steps, public health officials and healthcare providers can better address and curb the spread of syphilis within this vulnerable demographic.

For additional information on STI statistics, visit the CDC website: CDC STIs Surveillance.

Frequently Asked Questions

Why are sexually transmitted infection (STI) rates increasing among older adults?

STI rates, including syphilis, are increasing among older adults due to several factors. These include reduced condom use because of no pregnancy risk, increased sexual activity enabled by treatments like erectile dysfunction medications, and a general lack of sexual health awareness and screening in this demographic.

Are older adults less likely to use condoms?

Yes, many older adults are less likely to use condoms consistently because they are not concerned about pregnancy. This increases their risk of contracting and transmitting STIs, including syphilis.

What are the common symptoms of syphilis in older adults?

While early-stage symptoms like chancres are less common, older adults are more likely to be diagnosed with latent or tertiary syphilis. In these later stages, symptoms may be neurological or mimic other age-related conditions, such as cognitive decline, stroke, or neuropathy.

How do healthcare provider assumptions affect syphilis diagnosis in older adults?

Healthcare providers may not routinely discuss sexual health with older patients, leading to missed opportunities for screening. This oversight can result in a delayed diagnosis of syphilis, with the disease progressing to more advanced and serious stages.

Can older adults with unexplained neurological issues be diagnosed with syphilis?

Yes. Studies have shown seropositivity for syphilis in some older adults presenting with unexplained neurological symptoms, such as stroke, cognitive decline, and neuropathy. This can be a sign of late-stage or tertiary syphilis.

How has the incidence of syphilis changed for older adults in recent years?

According to a Fair Health study, syphilis cases among people aged 65 and older increased nearly tenfold between 2010 and 2023. Globally, many studies also point to a clear upward trend in incidence for this age group.

What public health efforts are needed to address rising syphilis rates in older adults?

Necessary public health efforts include increasing routine STI screening for older adults, educating healthcare providers about the risks and presentations of syphilis in this age group, and implementing public awareness campaigns to promote safe sexual practices.