Number 52, 2011
Equality of care for the elderly

Improving the quality of sex life in the elderly

Back to the Summary

J.M. Tomlinson, Sexual Advice Association, London, UK
Correspondence: J.M. Tomlinson, Sexual Advice Association, Bourne End, Church Lane, Holybourne, Alton,
GU34 4HD, UK. Tel: +44 (0)1420 82210; fax: +44 (0)1420 82210; e-mail: john@jptomlinson.com

Introduction
With the increase of life expectancy in both men and women far exceeding the biblical “three score years and ten,” the hope for many people with their improved health is to continue, if possible, to have a sex life. They want good health for both partners along with retention of their sex drive and ability to express it. Keeping sex alive in later years, therefore, is very important.
However, negative myths surrounding older men and women's sex lives still persist, although they are getting fewer. The idea that men and women reaching a certain age in their lives no longer need or want sex has long been held, and seems to have arisen from religious, social and cultural attitudes. It is still assumed, even by many older people, that there is no sex after menopause, and it is the same for men of the same age group.
Young people find the idea that their grandparents still have or want sex disgusting, unbelievable or impossible. Even many middle-aged people are taken a back at the thought that their own parents still want to express their love and affection in a sexual way. However, there have been a number of studies over the last few years assessing sexuality and ageing. As recently as 1977, La Torre and Kear [1] found that sexual activity in older people was considered to be “less moral and less credible than sexual activity in the young.” Since then, changes in attitudes are occurring, albeit gradually, and in a 1985 survey of American medical students, Damrosch and Fischman [2] found younger people thought a sexually active man or woman to be more content and more mentally alert compared with the sexually inactive.
Additionally, middle-aged children of older parents are becoming more relaxed and positive towards their parents’ need for sexual expression, although this relaxation has not generally been accepted as the norm yet. Despite the change in attitudes in the last few decades, there is no reference to sex and sexual health in the United Kingdom's National Service Framework for older people in 2010 [3,4].
Several factors can hinder people who are anxious to maintain their sexual relationships, the main one being aging. The latter affects men and women, psychologically as well as physically.

Aging men and sexuality
For men, the ability to get an erection, penetrate and ejaculate is what makes a man a man—a series of events to propagate the species and their raison d’être. To make matters worse, they feel they should be able “to do what a man has to do.” Not to be able to do any of these is humiliating and embarrassing and makes a man feel he has lost his masculinity. As he ages, it becomes more difficult to get and maintain an erection, penile sensation lessens, it takes longer to get to orgasm and semen quantity declines. A man may experience erectile dysfunction caused by medication, high cholesterol, high blood pressure and diabetes. Psychological causes of erectile dysfunction frequently include meeting a new partner after bereavement or divorce.
Anotherfactorthatcomes with ageislowerthan-expected testosterone levels [5]. This causes a series of symptoms, such as loss of sex drive, tiredness, profuse sweating, fewer or absent early morning erections with or without impotence, depression, aches and pains and severe mood changes, with marked irritability. Apart from just age, the physical causes of these symptoms are manifold and include diabetes (the metabolic syndrome), past infections such as adult mumps, mononucleosis, HIV infection, myocardial infarction, operations and alcohol excess.
Jackson [6] demonstrated that furred up penile arteries causing erectile dysfunction (ED) can be a 3–5 year warning that could be a precursor to narrowing of the larger coronary arteries within the next 3–5 years unless treated.

Aging women and sexuality
For women, menopause indicates a clear marker of aging around the age of 50, and is frequently called by women themselves, “the change” (of life). Many women have no idea what to expect in the postmenopausal era, other than what they have learned from their mother, and can be put off by their and their partner's altering sexual response. Irregular and heavy periods, hot flushes, night sweats and vaginal dryness can be very disruptive to a sexual relationship. Stress incontinence can also be a severe deterrent to having sex. This may present a point when a woman has a severe loss of confidence in herself and no longer feels she should or can be sexually attractive.
The lack of sexual desire, difficulty in becoming sexually aroused, orgasmic difficulties, as well as dyspareunia, which is the most common sexual complaint in older women, are major deterrents for a lot of women. A woman may regret the physical changes in her and her partner's body, the loss of the passion and sexual intimacy she had in the past [7]. Fortunately, for most women, this change is usually very gradual, and allows them to accept a different and often almost as enjoyable type of sexual relationship.

Improving quality
Fortunately, over the last few decades, enormous progress has been made in managing male and female problems, to their great benefit.

Men
Over centuries, a host of different weird and wonderful remedies have been suggested to help the impotent man. The great breakthrough for men and for their partners was the serendipitous finding of a drug— sildenafil, a phosphodiesterase-5 inhibitor (PDE5i)— to help overcome erectile dysfunction [8]. This drug revolutionized the sex lives of older men (and of many a younger man) when it became available in 1998 and proved to be the great breakthrough that centuries of men longed for to enable them to have a spontaneous erection. Other PDE5is—tadalafil and vardenafil— have joined sildenafil in the management of male impotence.
The second major difficulty that men find as they age is a loss of sex drive and ability, with a lot of nebulous symptoms that did not seem to connect up, such as tiredness, alteration in mood, depression, sweating, a “middle-aged spread” with a collection of central and body fat, loss of nocturnal erections, and the inability to get a spontaneous erection despite the use of a PDE5i.
The finding that a man's testosterone level, which gently falls as he ages, could fall low enough to cause these symptoms, led to testosterone-replacement treatment in the last decade or so (following a preliminary check of prostate specific antigen [PSA] to rule out current prostatic cancer). This greatly improves quality of life and libido, makes a huge difference to welfare and to a man's partner, and is frequently accompanied by a return of PDE5i-aided erections as well.

Women
Hormone replacement therapy (HRT) in women has been a godsend for many at the time of and after the menopause, despite the various alarms over the last few years over their safety. Tablets, patches, injections and implants have all been utilized, and local vaginal estrogen creams can be a very effective treatment in a great many women for dyspareunia.
Recently, it was realized that women who have had an oophorectomy lose most of their ability to manufacture testosterone, and replacement creams or patches have provided a huge boost to a women's desire for and enjoyment of their sex lives.
Finally, it must not be forgotten that both women and men who enjoyed regular sex when they were younger will probably like to continue to do so when older, wherever they live—at home or in a retirement home. It should be emphasized that an older man or woman having a sexual relationship with another elderly person does not have to entail penetrative sex. Older couples can enjoy touching, caressing and kissing sexually and get a great deal of satisfaction and fulfillment from it. But in care homes particularly, the staff need to be aware of their charges’ feelings, needs and desires and treat them sensitively [9]. Expression of this in a home is rarely possible unless the managers of the home are particularly sensitive to their residents and make it possible for couples to have privacy together, and not assume that arriving in a residential home means everyone wants to be celibate. In a survey of retirement homes, Bretschneider and McCoy [9], found that 62% of healthy men and 30% of healthy women over the age of 80 recently had sexual intercourse and that 82% and 64 % respectively had had physical intimacy. Unfortunately, there is a long way to go before this need is generally recognized [10].

REFERENCES